Archive for March, 2009

Fairytales and failures

[Before I begin, this is a long rant on the NHS and all that – some of you love it, some don’t. You have been warned]

I always loved morbidity and mortality meetings. The type of meeting that comes under the banner of audit and governance and all that. A good place to go and relive all the horrible mistakes that we all make and how we can learn from them.

There are all kinds of national organisations to point us in the right direction such as the healthcare commision, NCEPOD, and NICE.

They publish lots of documents and papers telling us all how we should be doing things differently and better. In the main these are largely good ideas backed up by fairly decent science. However they seem to fall down badly when it comes to real world implementation.

Such as the NICE guidelines on doing CT scans on head injuries, which were originally put-through a cost benefit analysis which predicted that the implementation of the guidelines (ie imaging far more patients than we currently do) would actually reduce admissions (as we wouldn’t have to admit people for observation as we would know there head was OK after a scan). This – surprise, surprise – turned out not to be the case.

Anyhow, the basic gist of the reports into best management and outcome is fairly straight forward. People should be getting more attention, more quickly and involvement of more senior doctors.

Now I would hardly call any of that groundbreaking. Surely anyone with an ouce of common sense can see that.

The issue as I say comes with the implementation.

[In America this is different. If something needs done, then you pay more for it. If you need more ICU beds in your hospital you pay for them. OK so this is simlistic but there is a rather more flexible pool of resources to draw on.]

The most recent “scandal” (as the daily mail would no doubt put it) was brought to media attention through the mid-Staffordshire hospital and a report by the health care commission. This had some juicy head line grabbing bits about receptionists triaging the patients and managers fiddling the figures so it got a lot of attention.

The hospital concerned is similar in many ways to where I work though it does seem some what more chronically under staffed and underfunded and if I thought the managers in my place were bastards then I clearly have a lot to learn.

Having said that, a lot of what I read (in the 176 page report – I focused mainly on the Emergency department bit) hit pretty close to home. A lot of the “critical incidents” concerning patient care would not be beyond the realms of possibility in any hospital I’ve worked in.

There were clearly a lot of serious issues in the management and running of the trust, but if a similar, wide-ranging inquiry took place at my hospital, there would be a lot of metaphorical skeletons (and hopefully not any real ones… i hope anyhow…) found in the closet.

And there is a very, very simple reason for all of this.

Too many sick people. Not enough resources.

Dare I make it as simple as that?

Virtually all of the recent initiatives to “improve patient care” in the NHS have focused (when you break them down) into improving efficiency of the health service. A lot of this is touted as being about providing better standard care for patients but it is mostly mutton dressed as lamb.

Everyone in authority –  the anonymous, faceless people high up the ladder it seems [My mate Tim who’s training to be a social worker says he sat in meetings with all levels of social workers and management and everyone was bitching about what a horrible system they worked in and how they were all powerless to change it. He sat there thinking – if everyone here thinks the system is screwed then who the flip is actually making this system the way it is] – is interested in squeezing every last drop of work and efficiency out of the resources in place.

There is a horrible misconception (so it seems) that we are making dishwashers or cupboards or something. As if the NHS is one big factory churning out well people.

There is a horrible misconception that a hospital provides the same level of care at 97% (or 100% or 110%) a it will do at 80% capacity.

Although capacity itself is hard to define. Hospitals have a flexible degree of capacity – we don’t tend to turn people away when we’re full, we just squeeze more in wherever we find the space. “There’s always the bunk beds” I say to the patients.

People who are stressed, hungry and in need of a pee (me, everyday in work it seems…) do not do their job as well as those who are calm, relaxed, with a full belly and an empty bladder.

Again, this seems fairly obvious.

If you want to measure quality of patient care there are a few fairly sensible ways to do so.

1) you can ask the patients – though often patients like comfy beds and nice car parks and a nice friendly doctor, who gives them antobiotics for the flu even though they don’t know their arse from their elbow

2) you can ask the staff- if everyone is pissed off, busy and stressed all the time and moaning about all the horrible things that happen to their patients (go on – ask me!) then something is probably wrong

3) check how often patients observations are done – this is probably the most basic aspect of nursing care, it shows how often the nurse actually makes contact with the patient

4) timing of medicine administration – if medicines are consistently late or missed then the nurse is probably too busy to do it

5) health care acquired infections – now this has attracted more attention than anything else in the media and it is a great opportunity for a fat, smoking, non-compliant patient to blame their poor health on the hospital and not the fact that they are fat, smoking and non-compliant.  Due to media attention this is currently top (and I do mean top) priority for many trusts –  mainly because of the media attention – I do not believe it should be top priority. None the less it is a reasonable surrogate marker of quality of care as it you will generally get more MRSA and C.Diff (and whatever other acronyms you might choose) in busier, less well equipped wards.

6) mortality – if more people die something is probably wrong. This first came to prominence with the cardiac surgeons who measured their outcomes at doing bypasses. This is a fairly peedictable procedure in a fairly homogenous population, therefore you should expect fairly standardised outcomes. The higher mortality rate in staffordshire is what prompted their inquiry. Though it must be said that standardising mortality rates across such a generalised population is very difficult and very easily skewed.

7) there also some fairly specific medical ones too – such as prohylaxis for DVT, door to needle/balloon time for heart attacks, time to antibiotics for sepsis – these are all what are referred to as standard of care.

What is perhaps not a good measure of quality of care is the wonderful 4-hour target for emergency departments. The problem is that there are two ways to fulfill that target:

1) you can appropriately staff and resource a department to assess, manage and treat patients as they arrive in the department

2) if that is not possible, you can just shortcut everything or fiddle the numbers. This is, unsurprisingly, much easier to do

Guess which one of the above happens.

It is not unreasonable to think that maybe people who work in hospitals are just like everyone else – ie lazy buggers who wouldn’t work in a fit. There are of course plenty of lazy people in the NHS, just like everyone else. Though even lazy people give a shit when they have to deal with sick people face to face. That old human element makes it hard to be a callous and lazy bastard.

I would also point out that doctors have some of the lowest sick day rates around. Turns out we actually enjoy our jobs. Given half the chance anyhow.

[as an addendum check out this blog on the BMJ website by the clinical lead in the emergency departement of the Stafford Hospital. A mix of humility, dedication and perseverance – good stuff]

Nice places to walk the dog – No. 1

[Part of an occasional series]

Brackagh Moss is a bog. Yes a bog. Us Irish like bogs. We were all born in one or something.

Anyhow. It feels like proper Ireland, the one before we chopped down all the trees and killed all the pagans.

Apart from the used condom at the entrance (dogs will find everything) it’s lovely. Though a tad damp underfoot. But you all knew that because it’s a bog…







How could I just kill a man

Just watched In Bruges.

Such a film.

I love them sitting on the bench rationalising their assassination and comparing it with the morality of helping little old ladies with their shopping.

The doubting, thoughtful, repentant assassin is a dying breed.

For some reason I don’t think it would work if they weren’t Irish. What does that say about us?

Love is a series of scars

“we try to make ‘love’ an individual emotion that does not ask someone else to suffer because of our love”

Resident aliens
Stanley hauerwas & william willimon

To protect the family name

I take part in a bible study on a Sunday morning in the house at the crazy early time of 0930. We’ve been running through the book of Acts and after 3 months we’ve made it to chapter 2. This could take a while.

Anyhow we’re at the bit helpfully entitled the fellowship of believers in the NIV. Which has this wonderfully radical bit about the believers holding the finances in common – which we have somehow managed to either spiritualise or edit out somewhere along the line.

But it also has this use of the word koinonia, translated as “fellowship” or by some as “the common life”.

I’ve been brought up in the culture where fellowship is either a cup of tea and a bun after church or merely as Christian banter – whatever that may be. So forgive me if i have a somewhat dim view of the word. Though I think we can redeem it a bit.

Anyhow we were chatting through today what we thought was meant by the common life of the believers in the early church (so early they hadn’t even worked out the name Christian or the word Church).

We figured this was a lot of things, including the financial aspect but perhaps the analogy of the family was the best. [Another clue that all the basic things than human beings do (marriage, family, kids etc…) point towards something bigger than themselves.]

When something in a family situation goes spectacularly wrong – divorce, alcoholism, unwanted teen pregnancy, unemployment, financial crisis – then it is the whole family’s problem, even if it is only the mum that has the drink problem or the son that got some girl pregnant. Families (in general) do not walk away from each other. They do not hold each other at a distance and view an individuals problems as just that – the individuals problem. Your problems become our problems. This is simply the way families work. Blood is thicker than water and all that.

And so when it comes to the church then is this the model we should be striving for?

[as a brief aside I am not so naive to think all families are like this – I just see this at work in mine and lots of others]

The skin of my yellow country teeth

On a slightly more positve note. And that wouldn’t be too difficult.

Come on the Ireland!

Though cutting it a little bit fine with all the silly dropping the ball and needless penalties near the end. Good flipping rugby game.

When it feels like you are losing

Distinct lack of blogging over past week. Mainly cause I’ve been too depressed to even get out of bed. It has not been a good week. So it goes.

Nearly 6 months have gone by since Da went. And i haven’t the slightest clue what to make of it all. Too many memories. So it goes.

Life is not easy. This is probably elementary to most of you. It is likely as plain as the life before you.  I’m only beginning to get used to the idea.

Anyhow. Wrote a song. If you’re gonna feel miserable you may as well get something out of it.


March 2009