Main theme of the week continues to be our urgent care pressures – it is still proving very difficult to break the cycle
Emergency pressures
The urgent pressures in our hospitals continue to dominate, the key being our inability to create sufficient discharges to free up the system and allow processes to operate smoothly. I am on call for the conurbation this week so have joined conference calls and it is clear the pressures are widespread. The entire system has been running at capacity for several months now, so small activity spikes quickly precipitate a crisis
It is impossible to be part of this and not form the view that we have to organise things differently. Too many years focusing on performance managing acute hospitals (because of targets) mean that other parts of the system now look unfit for purpose. Our new commissioning colleagues must look at how primary, community and social care operate in respect of urgent care – otherwise our ‘always open even when full’ hospitals will continue to struggle
Everyone now talks of the need for culture change in the NHS. One aspect of current culture is the ‘acutes are the problem’ mindset. The view that acute hospitals ‘drive demand’ by keeping capacity open, and swallow up disproportionate resource in the process, has led to too little attention on other factors that impact on activity and demand. The bizarre decision to reduce the acute tariff by 70% is indicative of this malign view of our hospitals, as are the swinging financial penalties for performance issues that are not completely within our control
The Transforming Community Services process was affected by this aspect of NHS culture too, resulting all too frequently in community services being placed ‘anywhere but the acutes’. Sometimes this may have been appropriate but, as a consequence, the creation of integrated services is now more problematic
Returning to the here and now (!) here are three practical steps discussed this week:
- On Monday (tomorrow) our new acute medical clinics open, at scale, to create and develop an increasingly ambulatory approach to our acute medical services. This is an exciting development that we have created jointly with our GP commissioner colleagues. Watch this space!
- We agreed a much streamlined process of recruiting to vacant clinical posts. Despite our best efforts, it remains slow to replace staff who leave. From now, the recruitment of most ward staff will start immediately the Ward Sister gives the go ahead.
- We have agreed to implement ‘supervisory’ Ward Sisters across the Trust. This takes these crucial people out of the ‘numbers’ and allows them to effectively manage the ward and their staff. Presently, with the best will in the world, they are simply too busy to focus on early in the day discharges, or spend more time explaining things to patients, or encouraging and supporting the development of younger colleagues.
These are significant developments, but I will continue to press for whole system change. It is increasingly apparent that acute Trusts will need to drive some of this too, by expanding their services into areas traditionally provided by others such as whole of year care and post-discharge re-ablement
Breast Friends meeting
Met with this group to update them on progress with this very difficult issue, and to discuss the thinking behind asking Sir Ian Kennedy to conduct a review for us on ‘raising concerns’.
We had a good discussion – the whole area of ‘whistle blowing’ is topical right now and I am hopeful that this review will result in some constructive and practical proposals for change
80 years of Birmingham Chest Clinic
Our city centre Chest Clinic celebrated 80 years this week. The teams provide a range of chest medicine and sexual health services from this old and characterful building. I saw fascinating demonstrations of the work carried out on tuberculosis, occupation lung disease and lung fibrosis, and our Chairman made a presentation to a member of staff who has worked there for 50 years!
I also bumped into a recently retired consultant who taught me as an apprehensive junior medical student. It wasn’t quite 50 years ago but suffice to say that I recall watching the Falklands Task Force sail on TV in the students common room, and our ward was in the ‘new block’ that is now the oldest building on our site!
@simonRdodds
Hi Mark,
Yes, the 4 hour A&E target breach data for HEFT over the last week has been the worst I have seen over the last four years. This is a symptom that the whole system is failing – A&E waiting times are a sensitive indicator of whole system flow slowing down. The data says that admissions have not significantly increased so the “problem” must be internal queues in the acute hospitals. A couple of years ago I created a “Save the NHS” computer game that was designed to illustrate this whole system “deadlocking” and one of the causes of it – distrust. So if anyone wants to download and play it the link is:
http://saasoft.com/6Mdesign/
The game and instructions are at the bottom of the page.
I used this with a group of 40 surgical SpRs last week – and much to their surprise and disappointment they managed to “blow up” the hospital too with their “intuitively obvious” solutions. They were even more surprised when I demonstrated how to use the available information to “diagnose” to root cause of the problem and to logically, rationally and safety solve the problem (reduce cost by 20% without increasing mortality). Their final question was “Where can we learn more about this stuff?” which I took to be a more constructive response. S if anyone reading this wants a webex demo please let me know – it works better as a dialog.