Lies, Damned Lies and A&E Statistics

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First, the 4-hour emergency department (ED) target is NOT A TARGET FOR PATIENTS TO BE SEEN IN ED and never has been. Let me repeat that – it not a target to be seen.

The target is to be seen and discharged from ED. That might be home or it might be transfer on to a ward or it might be transfer to another hospital.  The term “seen”, widely used by the media, suggests it will take that long for a doctor to see you which is untrue.

Indeed, many patients attending ED many not even need a doctor – many minor injuries can be managed by nurse specialists or advanced nurse practitioners.

Why is Emergency Medicine struggling to recruit?

I know three anaesthetists, who are all former emergency medicine (EM) trainees. Although I haven’t worked in EM myself, I have worked in a trust whose (ED) had its trainees removed due to poor training. Work was then provided by locum EM doctors.

(There 4 basic grades of doctor – F1, SHO, Registrar/Staff Grade, Consultant. In new money, that’s F1, F2/CT, ST/specialty doctor/middle grade, Consultant but the old terms are still used.)

This can happen in any department: the workplace does not provide good training; it therefore doesn’t attract the best consultants; it has poorer outcomes, has difficulty attracting staff, is overworked and develops a negative culture; it provides poor training and in the worst cases (as above) it loses its trainees; and so the cycle continues. Breaking it is not easy.

Is this due to the targets in ED? Maybe but only partially. Unfortunately, I can’t find the anonymously written article in the Guardian where a doctor explained she enjoyed emergency medicine…which is why she became an anaesthetist.

One of the aforementioned former-EM, now-anaesthetic registrars pointed out to me, that given anaesthetists cover critical care out of hours in most of the country, it is actually them who sort out the worst emergencies, not the EM doctors. Most are sorted out in the ED, but often it is critical care rather than EM who have the skills to provide more definitive treatment.

It’s not universally true – a surgical registrar discussed a hospital where actually EM rarely called anaesthetists unless they were certain a patient needed to go to critical care or theatre. And even then, the patient would be intubated, have lines put in and be ready for transfer before coming to critical care. In all the hospitals I’ve worked in, not only would this not happen, EM consultants didn’t have the expertise to even do it.

What the hell do you know, Raj?

It should be noted, this is not the experience of an EM registrar but an anaesthetic and critical care registrar on the receiving end of referrals. But it is problematic when, as was the experience of a GP friend, the locum EM registrar in your department is in fact a plastic surgery registrar whose qualifications and experience from abroad have not been examined properly. I have certainly worked with EM specialty doctors and more worryingly consultants whose practice left something to be desired in my, my anaesthetic and critical care colleagues’, and my EM colleagues’ opinions.

The sort of situation described above, where a patient can be stabilised in A&E, may very well be a thing of the past. A not-uncommon complaint is senior doctors spending the bulk of their time trying to discharge less sick patients quickly, rather than helping in the resuscitation room because other specialties (such as general medicine or intensive care) can cover for them there.

This is not universally true and I’ve worked with excellent EM consultants and registrars who leave only when there is nothing more to be done but there is an understandable pressure for them to meet targets. Indeed, talk to folk who worked in ED before the 4 hour target; I’m not sure an 80 year-old waiting 12 hours on a trolley in a corridor with a broken hip represented a better run department.

EM is an amazing mixture of the minor and major; doctors who can suture scalp lacerations, stop nosebleeds, manage suicide attempts and run trauma calls and cardiac arrests. It is a also specialty which begs to be done at less-than-full-time (say 80%) – continuity of care is a non-issue but burnout potentially is, especially given the ridiculous rotas for its trainees (8pm-4am? That cannot be good for the soul).

Who knows? Maybe they’ll even get to manage some emergencies rather than having to discharge patients with “non-cardiac chest pain” at 3 hours 59 minutes. Also – watch Cardiac Arrest. It’s really good (if old).

 

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Some thoughts on This Is Going To Hurt

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Firstly, This Is Going To Hurt by Adam Kay is a great book. A former obstetrician who gave up medicine in 2010 to pursue comedy, his description of what life used to be like is as with any well-written memoir of medicine heartbreaking and funny. Indeed, variations on “heartbreaking and funny” have become something of a cliché in reviews of the medical memoir.

It is worth noting how variable our experiences in the NHS are. A persistent theme in This Is Going To Hurt is the absence of bosses. This varies widely between specialities. Anaesthesia has always been ahead of the curve in terms of consultant presence out-of-hours but consultants in all acute surgical specialities (including obstetrics and gynaecology) seem, from my point-of-view anyway, to be more readily available than in years past though many internal medical specialties still seem to lag behind. “I didn’t want to disturb the boss” is no longer a legally defensible position.

When Kay started medicine (in around 2004), 24 hour on-calls were the norm. Not bothering the boss was the norm. Now, the European Working Time Directive means that 12 hour shifts are in place for nearly every acute specialty. Though much-maligned, the new junior doctor contract has led to exception reporting which fines trusts for junior doctors who persistently working hours longer than contracted.

(The fines go back to the junior doctors’ mess and the doctors in question should they accrue sufficient hours get days in lieu.)

Many of the bugbears he discusses are still in place. The lack of study leave for exams – public health get two days a week for three months coming up to their exams; I get the day of the exam off plus a day for travel. The difficulty in getting swaps for annual leave, made even more complicated by the fact that on a 1 in 7 rota with 12 hour shifts, for any given day off, 1 or 2 of the other 6 doctors are likely to be unavailable for swaps.

Some are worse, particularly the inflexible and pernickety nature of postgraduate education. Not got a DOPS in Management of Cardiorespiratory Arrest despite having a valid ALS and this being a thing that happens out of hours so there is almost never a consultant around to watch you do it? Too bad, you may have to repeat the year. Not got any assessments in major trauma despite not having worked in a major trauma centre? Too bad, you may have to repeat.

I guess the bottom line is – some things are better, some things are worse and the experience is dependent on specialty and location as much as anything. Slowly (too slowly) the machismo in medicine is dying away. But there is still a feeling of too much work for too little pay with the addition of tiresome educational assessments, the value of which is never truly made clear to assessors and those being assessed alike.

Labour don’t need a position on Brexit

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Let’s assume that before Brexit, Labour doesn’t win a general election. Whilst Theresa May calling one is possible, there doesn’t appear to be any specific desire for one. Admittedly, I and everybody else including the cabinet said that last time but anyway.

Currently, Labour’s position on Brexit – or rather lack thereof – has made no difference to their polling. They have no incentive to change. The Conservative approach to the negotiations has been so cack-handed that all Labour have to say is “we wouldn’t have been this rubbish”.

Liberal Democrats and Greens can argue Brexit is a disaster but the public is so far judging the government on their incompetent negotiations, rather than the idea of Brexit per se. I can’t see any good electoral reason for Labour to clarify its muddled position and risk alienating either their Leave or Remain voters.

Even after Brexit, Labour don’t need a position. They simply say “Brexit is done now and it has been done disastrously – vote for us, we wouldn’t have screwed it up and will get you out of the mess”. Perhaps Labour’s “Coalition Of Chaos” poster (reverse engineered from the Tory one after this year’s election) may resurface.

Nonetheless, with voters and a party split, I can’t see why Corbyn would be in any great rush to take a definitive position on the issue, much to the chagrin of Remainers, particularly Labour ones, everywhere.

Addendum 23/9/17: I assumed this would be read by 4 of friends on Facebook who know I’m a Liberal Democrat. Then one of my Labour friends shared it and so the readership had gone up to 8, some of whom seem to think I’m a Labour member advocating this.

I think Corbyn is an awful person who should take a stance on Brexit. This post is merely an observation of how avoiding doing so may help him win.

What for the Liberal Democrats now?

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As of this writing, Theresa May has agreed to a “confidence and supply” agreement with the Democratic Unionist Party. Nick Clegg, whom I campaigned for, has lost his seat with losses by 105 in Ceredigion, 45 in Richmond Park and most heartbreakingly 2 in Northeast Fife to boot. This has made the increase in Liberal Democrat seats from 9 to 12 bittersweet.

I’ll only talk briefly about Sheffield Hallam; how Nick Clegg lost to a unapologetically leftist Labour party in one of the most affluent constituencies in the country may be puzzling. Simply, Tories voted Tory and many students plus some left-wing Liberals voted Labour. The Liberal Democrats only lost 2000 votes and Labour only gained 2000 but it was enough. Sheffield Liberal Democrats may read this so a full examination now is not my place. For me it is sad to see a man gone whose decisions pushed me to join a party and campaign.

A new leader…

Many will argue Tim Farron underperformed. The second Brexit referendum message did not work. Half of Remain voters now support Leave, giving Leave 68% of voters. 30% of 2015 Liberal Democrat voters voted Leave; how did it make sense?

To be honest, he didn’t have a chance. Assume the election is in 2020. The second Brexit referendum becomes a foundation from which to build. Between March 2019 and May 2020, Liberal Democrats propose plans to deal with a calamitous Brexit. Our predictions coming to fruition gives us the authority.

Whether you agree with that counterfactual, the snap election meant we couldn’t retract that message. Lib Dems would have haemorrhaged votes if they had U-turned. Further, we’d have lost the large number of new members and volunteers making winning even more difficult.

Nonetheless Ed Davey, Vince Cable and Jo Swinson have made welcome returns. A third of our MPs our now women and Layla Moran of Oxford West and Abingdon is – I think – the first Palestinian-British MP. I’m not sure now is the time to be picking a new leader. Let’s keep things strong and – erm, on an even keel.

…or a new message…

Tony Blair – Things Can Only Get Better
Barack Obama – Yes We Can
Trump – Make America Great Again
Vote Leave – Take Back Control

I don’t have the 2017 results yet but look at the 2015 results. Since I kind of like spreadsheets, I spent some time fiddling with them. Let’s say we win the 8 seats we did with majorities of 1 (ie beat the other person by 1 vote only). And we win another 318 seats by 1. We’d have 326 seats ie a majority.

In order to do this, we’d need an extra 4.9 million votes (4903316 to be exact), or around 15% of people who cast a vote. These numbers are silly and impractical; I say this only to highlight the importance of targeting.  Winning in our electoral system isn’t about convincing everybody.

The four slogans above (though strictly Blair’s was Because Britain Deserves Better but nobody remembers that) have a lot in common. The only word with more than two syllables is America. They’re short and snappy. The last two have elements of assonance and alliteration. They’re positive. They conjure the idea of change.

So why did Strong and Stable fail? Well, campaigns also have to pass the sniff test. Does it “feel” like it makes sense? You can’t run on stability and then do U-turns. But often campaign failures go further than that. Hillary Clinton (Ready For Hillary) and Stronger In (Harder Better Faster…just kidding it was Stronger. Safer. Better Off. Probably) didn’t just have poor slogans – they lacked a message. Stronger In was persistenly undermined by wild claims about average loss of earnings and emergency Brexit budgets. Clinton…well, I’m still not sure what her message was.

…and if so, what?

To build a message, you have to start with an idea. Who are we? Well, we’re liberals. Which is so vague and fluffy you could barely convince a child it was worthwhile let alone an electorate. The party is split along the lines of Orange Bookers and Yellow Social Liberals. Economic and social liberalism have not always been easy bedfellows and the fault lines between the SDP’s social democracy and the Liberal Party’s classical liberalism still hinder the party.

I don’t believe they should. Economic and social liberalism are not mutually exclusive. Further, they are necessary for one another. A failing economy leads to unemployment and inflation. If you can’t afford food and heating because prices go up, you’re more likely to get sick or do badly at school. If you have no job, crime may be the only option.

An effective welfare state reduces sickness, trains and educates people and gets them back into the workplace. It is worth spending money on. Thatcher’s legacy of failing to pay for a welfare state can been seen in the mining towns and villages across South Yorkshire. Blair believed that unfettered free markets would give traditional Labour voters jobs – it didn’t as their skills were rendered obsolete and a crushing recession after his resignation meant they struggled with what little they had left.

Brexit

Too few people care about Europe for it to be an electoral issue. When the next election will be remains uncertain but the emphasis cannot be on staying in the EU. Brexit is, I think, an inevitability. Whether or not the second referendum stays as policy, it should be quietly pushed aside – we need a plan for Brexit.

The case should be made for free trade and the positives of immigration. Come the 29th March 2019, I have no doubt the Conservative government will have screwed this up. Royally. We have to have a positive alternative. Change Britain’s Future is a solid slogan (though I humbly suggest Change Your Future or Change Our Future for the, er, future). Indeed, there is something in the Republican notion that you can “pull yourselves by your bootstraps”.

The bottom line is a plan for a post-Brexit world. One where we show why it matters that we reach out to Europe and the rest of the world. How the Polish fruit-picker means the farmer in Lincolnshire has a job. As does the lorry driver who moves the produce and supermarket cashier who sells it. The mechanic who fixes the lorry and buys parts from Germany because of the trade deal we have – but rather than framing these as costs, these can be framed as opportunities. Immigration can create jobs for the many, not…the smaller number.

But moreover, how that money can be ploughed back into deprived areas. Into retraining the everybody for the onset of new technology.

We can be for both and we should be and we have to be.

Will it work?

No idea. May be this is all rambling. I’m not a seasoned campaigner, an expert in polls or a politician. I’m not clear we can successfully sell immigration to a skeptical electorate. Though most people’s number one reason to vote Leave was sovereignty, not immigration, this doesn’t say how important immigration was to them. I wonder if it is still too early to be talking about free trade in an increasingly isolationist Britain.

But if we can back the slogan – Change Britain’s (Your?) Future – with an idea, the idea that we can build a welfare state that creates a booming economy in the wake of Brexit to pay for that welfare state, may be we can sell it to 5 million more than people in 2022 that we did in 2015. Unless we do this all again in October…

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.

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.

 

“No Black No Dogs No Irish” and other thoughts on the EU

I am scared of leaving the European Union.

A not insignificant number of my friends are Leave supporters. I have little doubt they genuinely believe leaving the EU will be of benefit to them. Whether their arguments are about sovereignty or the economy, they’re intelligent people who are appalled they are on the same side as Nigel Farage and George Galloway.

However, there is an undercurrent of fear of the other percolating Leave. Regardless of Boris Johnson opining his love of immigration or indeed that an Australian-style points system would lead to more immigration, much of Leave’s support comes from those who are scared that foreign people make things worse.

To a certain extent, I’m not making a logical argument. It’s that if a politics of populist fear succeeds, it paves the way for more. Fear of the other is the cause of your problems. We need less ‘other people’ and more ‘your kind of people’.

That was, when my parents came to the UK and my brothers grew up, the norm. The National Front were popular in the 1970s. Rivers Of Blood and “if you want a nigger for a neighbour, vote Liberal or Labour” still echoed in the ears of immigrants. Even today, for 10 years David Cameron has espoused anti-immigration rhetoric that has now undermined anybody’s belief he supports any pan-European project.

I worry that that social progress will go backwards, even just a little bit. I don’t want to live in a country where that fear is stoked and where that is a legitimate way to win elections.

This referendum is for me whether Britain feels it wants me to be here. So I will campaign for Remain tomorrow. Largely, this will be genuine passion for the EU; partly though it will be out of fear.