A&E is not in crisis – It’s doing what it does best

07. January 2015 · 2 comments · Categories: Healthcare Delivery · Tags: , , , , , ,

We set a new precedent yesterday in one of our A&E’s. Over 400 patients attended and we admitted over 60 patients in one 24 hour period. This is unheard of – a normal ‘take’ in one of our hospitals is 25 – 30 patients from 200 attendances – yet for the last few weeks we have been routinely admitting in excess of 100 patients a day across our two hospitals.

We set another precedent this week as well – we discharged over 200 patients in two days. That is an astonishing number. Of those 200 discharges how many might you think were discharged to the care of social services? The answer is zero – because those two days were over the weekend shortly after the New Year bank holiday. In the same period the number of ‘delayed transfers of care’ has risen to 70 and the number of ‘medically fit for discharge’ (patients no longer requiring medical care but not safe to go home for other reasons) is another 20 or so on top of that. That’s three (unfunded) wards full.

We are under intense pressure – our staff are performing a herculean task – admitting and caring for the sick – shepherding them through the system – and organising safe and efficient discharge – and keeping the floor in A&E safe – just about. That task involves over 60 different professionals for one patient from the triage nurse at the front door through to the community therapies staff that in-reach into the hospital to pull through patients into our intermediate care facilities via the typically three or four different medical teams that might care for one patient during a hospital stay (A&E team, Acute Medical Team, Medical specialty team, MFFD team) – Not forgetting the critical care team that receive the 5% sickest patients on the way.

Yet we are coping. Whilst we have hit ‘Level 4’ at one or other of our hospitals on a few occasions over this period of ‘crisis’ we have never considered ‘closing our doors’ as some others have. And I am convinced I know why.

Synchronous Coordinated Action

Our hospitals march to the drum beat of the two hourly bed meetings. These are brief (less than 15 minutes), always at the same time (8,10,12,14,16,18,20:00 hrs), teleconferences, involving representatives of every part of the pathway from the front of the hospital to beyond the back door, consistent – run to a script, informative – everyone knows what they need to know and leaves knowing what they have to do (discharge 6 patients, 2 before lunch!). A nurse in charge of a community ward will know what the wait times are in A&E. All the time actions are followed up by the operations centre staff – our ‘air traffic control’.

Control of our Outflow

Just over two years ago our Trust took the strategic decision to – ‘move down the value chain’ – we run community services for over half our population and have developed intermediate care facilities in community locations around our catchment area. We are ‘in control’ i.e. have direct access to nearly 100 community beds – including ‘medically fit for discharge wards’ closely co-located but separate from the hospitals and run by GPs.

This has saved our bacon this winter. Its not been plain sailing – it has taken several weeks to get the ‘drum beat’ working consistently and reliably and there have been times when the acuity of admissions have been such that discharges haven’t happened for the ‘right’ reasons and this has threatened to overwhelm us. We have panned the 4 hour target like everyone else – but we’ve done alright for our patients. I am intensely proud of how well our Medical, Nursing, Therapies, Operations and Community staff have pulled together to pull it off.

Its not an A&E Crisis

A&E waits are a symptom of a failing health and social care system. A&E is the only point of care that is consistently available 24 hours a day. Everyone knows where it is, that its always open, that there will always be a doctor there and that you will get free treatment if you need it. People vote with their feet – other parts of the system are either not trusted or simply not available when needed.

The ‘A&E crisis’ is a consequence of un-restrained inflow and significantly constrained outflow. Neither the ‘inflow’ nor the ‘outflow’ is incentivised or held to account for the demands it places on the hospital. It is being in control of at least some of our outflow that helped us weather this particular storm. And therein lies the solution to the problem – if we want hospitals to ‘succeed’ then they must be in control of the resources of ‘outflow’ services and probably ‘inflow’ services as well.

At the moment the philosophy (if organised thinking is a suitable way to describe it) behind the Better Care Fund (The pooling of health and social care resources) is moving in diametrically the wrong direction on this. BCF is moving resources out of health into social care – on the face of it in order to prevent admission to and promote discharge from expensive hospital care. It will not work – however well meaning – it just won’t. Whilst depleted resource in social care is an issue (and a worsening one) fundamentally the issue is one of accountability and control. As long as the services that provide care before and after hospital experience no cost or consequence for sending a patient to or keeping a patient in hospital then they will continue to behave as they always have done. And as these services gradually fail medical takes in hospital of 60 or more will become the norm not the exception.

Mind the Gap – The Calamity of Adolescent Mental Health Services

16. April 2014 · 1 comment · Categories: Leadership, Patient Safety · Tags: , , , ,

We had an ill child in our A&E for over 20 hours yesterday. Read that again – yes its true – 20 hours in an inner-city A&E – on a Friday. Actually she isn’t a child – according to half the professionals that saw her, but was according to the other half. Conveniently for each of them they were able to define her in a way (wrong side of of her seventeenth birthday) that meant neither had to take responsibility for her. A definitive safe place of care was eventually found at an adolescent mental health facility over 100 miles away. Throughout this whole episode she was suffering an acute psychiatric illness.

Fragile Minds

After toddlerhood – adolescence is the most active phase of brain development. It is a critical period during which personality, skills and traits are developed that set the patterns of mind, thought and behaviour for the remainder of adult life. It is a crucial phase of transition from childhood to adulthood – a period of ‘finding ones place in the world’ apart from the security of parents and family. It is an intensely psychologically vulnerable time – one of which we all have memories of our own we would probably rather forget. It is also the commonest period of life for mental health issues to first develop – by some estimates up to 20% of adolescents and young adults are experiencing some degree of mental illness and over 40% of adult mental illness commences in the adolescent period. The combined assaults of alcohol, drugs, sex hormones and dramatic changes in life circumstances on a fast developing brain have unpredictable consequences – which for a growing minority include breakdown, psychosis and the roots of devastating life long mental illness.

When your world falls apart

Psychosis is the most terrifying symptom of disease. It is the awakening of primal fears – normally locked away by evolution and civilisation. Psychosis is the manifestation of every self doubt and vulnerability we harbour, a total loss of security. The very ground you stand on loses its solidity, the certainties of perceived reality evaporate. Paranoia is intense, everyone is against you, every sound becomes the whispering taunting voices – undermining and aggravating self doubt.

During this potentially lethal psychological experience – our service finds it most appropriate to leave the sufferers sitting in A&E cubicles, overseen by security guards and witnessed by the drunken fray that make up the core clientele of A&E on a friday night. Meanwhile professionals play ‘pass the buck’ – skulking guiltily in the background too nervous to engage with a ‘difficult teenager’ – the behaviour surely being noticed and fuelling the paranoid beliefs of the patient ‘for whom no-one cares’.

Why do we do this? Why do we let down such a vulnerable group in such a catastrophic manner?

Too Special to Touch

Throughout my career I have witnessed, and been exasperated by, the phenomenon of medical super-specialisation. This is the process by which small groups of sub-specialists – usually based in well resourced centrally located university hospitals – develop standards of care for a sub-set of a population with a branch of a disease that produce significantly superior outcomes for those patients. This isn’t a problem in itself – this is how the frontiers of medicine move forwards. The problem arises when this standard of care – attainable in the rarefied environment of the academic centre – becomes the expected standard in all healthcare settings. A process of centralisation of care then ensues – as ‘good enough’ becomes the victim of ‘perfection’ – standard care in general settings is discredited. Generalists are stripped of the right to provide certain aspects of care – patients are diverted to diminishing numbers of ever distant specialist centres – as the skills for providing even ‘good enough’ care at local centres evaporate.

One of the most striking areas of medicine where this has happened is children’s services. Most paediatric services are now provided by centrally located children’s hospitals – these highly specialist tertiary centres do a fantastic job – but to survive they have had to grow their business ‘down the value chain’ to the point where they now also provide the bulk of standard secondary care. This has resulted in the shrinking of paediatric services in district general hospitals to below critical mass levels – many paediatric services have closed – many others are teetering on the edge of viability, even in quite large general hospitals. It is reaching a point where in many hospitals it is just unsafe to be a child – and the doors are simply closing on them.

This march of progress wouldn’t be a problem if wasn’t for the fact that very sick children – whether physical or, as in our story above, mental – still come to A&E expecting life saving treatment. Our doctors, with dis-credited general skills, diminished exposure and experience – are not only discouraged but actively criticised for trying to provide good enough care. So they have stopped – and patients languish in A&E awaiting transfer to over subscribed specialist centres – not receiving immediate care they need that might prevent harder to treat long term conditions. Meanwhile the generalist tiptoes around them – too terrified to touch.

A Relentless Epidemic

Childhood and adolescent mental health is very special indeed. Most ordinary doctors are scared of mental illness – this is hived off very early in training – and even more scared of children. Yet the story of our seventeen year old in crisis is becoming more not less common, what was a handful a year presenting to our A&E has become dozens a month. We don’t know why – but the wide availability of cheap alcohol, potent cannabis, met-amphetamines, and other ‘legal’ highs along with the as yet un-evaluated impact of the psycho-social complexity of a life lived ‘on-line’ must all be playing a part. And this is a drama that is being played out in emergency departments across the NHS – daily.

There is an urgent need to find a solution for delivering safe ‘good enough’ care for these patients – at the point of presentation – until a place of definitive care can be found. The needs are not complex – but they do transcend organisational boundaries – the ability to provide safe dependable holding treatment in an urgent mental health situation – is a good test of health system integration. The care of the intoxicated, potentially physical injured patient that is in the throes of a mental health crisis requires professionals that normally work in isolation (traditionally somewhat distrustful of each other) to come together and meet the physical and psychological needs of these patients.

Above all this needs system leaders to come together, organise their services to deliver and demonstrate that – yes, we do care about this calamity – we care very much.