Raconteur is now a medical consultant in a DGH

Post research and now a medical consultant in a DGH. Said DGH is, in common with many others, being actively inspected by CQC. I could fill pages on why CQC has been more active post-Berwick report and the how the hospital's finances has been destroyed by tariffs for common procedures coming down year after year due to the so called efficiency savings. I could also write on how the hospital is not paid properly for increasing A&E admissions. For those who don't know, the hospital is not paid if it admits more patients as compared to previous years and it is not paid if the patient stays in more that 'x' no. of days. When medical admissions are rising year by year and revenues are falling due to efficiency savings, the hospital is also expected to hire more staff to make things safer. Post CQC visit in couple of years ago, the trust hired 200+ extra nurses and some more doctors. Currently the trust is in severe deficit, in common with most of the acute medical trusts. Meanwhile, emergency admissions rose to unprecedented levels this winter, eased off a bit in May-June and is now climbing back to winter levels again. No summer respite this year. Combined with increased frequency of CQC visits, monitor and NHS England visits - it is caught in a bind. I don't see any good solutions - the Lansley act has destroyed many institutions and fragmented care. I work for the hospital, but couple of other organisations who have won bids to operate certain 'services' then pay the hospital for me to operate clinics on their behalf. I get one salary from the hospital, but work for 3 different organisations who each have their own IT systems which don't talk to each other. Bureaucracy tripled and IT systems proliferate and patients get fragmented care and my stress levels hit the roof trying to get patients a similar level of joined up care between 3 different organisations. The purpose of the act was to increase efficiency and drive down the costs by making each service go to the cheapest provider. If you have different organisations involved - primary care organisation, hospital and then external organisations which are not NHS but private or 'community' enterprises running cardiology, diabetes, ultrasound, physiotherapy, COPD, podiatry, occupational therapy etc, then joined up care is well nigh impossible due to the multiplicity of providers each running its own medical records, its own IT systems, governance systems etc. Work is duplicated and efficiency is reduced and costs increase. How did the authors of the Lansley act think this would pan out? They had to know that this kind of fragmentation would result in increased costs, bureaucracy and be detrimental to patient care. Enough people told them that at the time and they chose to ignore it. Now we have to bear the brunt of it and patient outcomes are not worse only because we work harder to prevent chaos between organisations. Rant over

Going through a phase of book reading.

good ones recently - Elizabeth Kostova- Historian
Irvin Yalom - Schopenhauer Cure
Muriel Barbery - The Elegance of Hedgehog

In research land

Away from patients for a while now. I am in research and teaching land.

GPs and medical registrars

GPs are being pilloried from all sides now. They are under tremendous pressure politically. Hospital doctors' view of them is tinged with envy for their lifestyle and money mixed with mild contempt as they are seen to have opted out of the tough parts of medicine.
I try to see things from their perspective. We, that is the hospital doctors, moan about the amount of paperwork, this is nothing compared to the mountain that the GPs have to go through. Most hospital doctors will be nonplussed to be put in a clinic with no quick access to basic investigations or indeed no way to pick the brains of their colleagues from other specialities. GPs regularly work with no support at all. We have our share of time wasters, nothing I guess compared to the amount of people GPs have to see who have nothing wrong medically.
I've seen a lot of hospital doctors whinging about GPs, sometimes where the patients can hear them! I usually have a quiet word with my juniors if I hear them doing this. Not only unprofessional but also very dangerous to the GP concerned.
I field a lot of enquiries from GPs, mostly when I'm on call and also as an endocrine registrar. Some are genuinely difficult problems and some make me wonder why they just don't open a text book or google it. Some questions are so ludicrous that I wonder how they passed out of medical school, pause, take a deep breath and remind myself of surgeons and psychiatrists who are much worse than this at general medicine and reply politely.
Worst GPs I find are who sent people into hospitals either exaggerating their symptoms, mostly in order to bypass the clinic waiting times or who know perfectly well that it is a social issue/non-medical issue and sends them in any way, to an overcrowded hospital with no beds available. There are admission avoidance and social teams available pretty much 24 hrs where I work. Worst offenders are out of hours GPs, I find. The hospital I work in has >95% bed occupancy rates, we never have a free acute medical bed.

Punter comes into hospital and I ask
'Did your GP see you?'
He says, 'No but I spoke to him on phone and he called an ambulance for me.'

This for a purely social admission! Often the OOH(out of hours)GP doesn't know the patient at all and thinks, 'this is too complicated for me in the middle of the night, let me sent him to the hospital and they can sort him out'. Which is fair enough I guess, but annoying none the less if you have no beds a lot of sick patients to sort out in the wards and the admissions are piling up. Worse if you find that there is nothing much wrong with the guy and the GP hasn't actually pulled up his old records or indeed hasn't seen him at all.
I shudder to think what will happen when we have polyclinics and GPs won't know their patients at all. 99% of GPs I deal with are reasonable and conscientious, but as with all professions there are the lazy and the bad ones. Amazing how often they end up as locums and OOH.
When you think about it dispassionately, GPs are such good value for money for the country that the idea of getting rid of traditional GPs for polyclinic led service is mind bogglingly stupid. I agree that polyclinics may be useful in some urban inner city areas which are poorly served in term of numbers of GPs. The idea however that each PCT must have a polyclinic is so patently ill thought out that the ministry of health must be forced into to a rethink
We already have built in polyclinics, they are called district general hospitals(DGH). We need to streamline the working of hospitals and integrate it with existing GP surgeries so that they have quick access to the facilities. For that we need the PCTs to commission local hospitals for their diagnostic services instead of parcelling it out to different private outfits. We need to integrate GP computer systems with hospital ones so that they have access to investigation results quickly.
There are so many simple and cost effective ways these and other things can be done, instead of spending massively to build new polyclinics. All it needs is intelligence and common sense at local level, blunting the internal market a bit so that short term cost is not the overriding issue but long term cost effectiveness/patient care is the issue.
Polyclinics will not only sound the death knell for the traditional GP surgeries but also will put most of the DGHs into financial doldrums. Most of them are already in the red, if they have to compete with polyclinics for providing diagnostic and therapeutic services they will face financial ruin. The way most DGHs finance their acute ans emergency care and inpatient care is from outpatient clinics and diagnostic services. If they are removed to polyclinics, most hospitals will have to shut down.
Then we will see fewer larger hospitals and polyclincs - and huge increase in health expenditure. Has the government thought of the implications of this? Are they prepared to raise the taxes and NI contributions, some how I don't think so.
This has been discussed ad nauseum I guess in different medical blogs, but I feel saddened and angered at the waste and short-termism of current NHS policies and I need to let it out a bit.
Long rant, but I have the day off after nights.

Night on-calls

Interesting week of night on-call. Was busy the first two days and then it was better. One very sick patient went to ITU. The other sick ones we managed to keep alive.
The one that went to ITU had sepsis with low blood pressure and acute renal failure. Put in a central line and poured fluid down her. But persistent low blood pressure and kidneys failed to recover enough. So off she went to ITU. The other really sick patient had similar features with added history of heart failure, which combined with acute kidney failure meant a slightly more cautious approach. Surprisingly enough second chap recovered better that the first one who had a better state of health prior to getting sick. Vagaries of human body I guess.
Often it is for the one to one nursing care and monitoring that we transfer to the ITU. In a general ward especially at night there are two trained nurses for upto 30 patients and 3 doctors to cover 300+ patients and all the new admissions. So if you have a really sick patient you are so relieved when ITU takes him off your hands, otherwise you will soon have 5-10 new patients to clerk in and decide a management plan on and all the sick ones in the wards. Solution increase the number of bodies on the ground.
That can't be done because of the European working time directive, I mean it can be done but the hospitals will have to hire more juniors which they can't because most hospitals are in financial trouble.
You hear about the NHS surplus this year. This is with the primary care trusts(PCT) and not the secondary and tertiary care hospitals most of which are just viable or are in debt. There is no way to redistribute this. All because of the internal market set up by Tories and strengthened by Labour. This means the PCTS get all the money and then commission the hospitals to take care of the patients. The hospitals then bill the PCT. There are so many restrictions on the hospitals claiming the money back from the PCTs so practically most hospitals do twice or thrice the amount paid by the PCTs. However the hospitals can't not treat the patients, which means it ends up footing the bill. PCTs end up in surplus and hospitals in debt.
I think I've ranted enough today

Weekend on calls

Was on call last weekend. Not horrendous. Usual barrage of patients with a few really sick ones. Usual dictum is hospitals is that the medical registrar's job is the worst in the hospital. You get dumped on by every specialty in the hospital.
You get cardiac arrest calls, 50-60 admissions, referral and reviews from all other specialities and you are responsible for another 300-350 patients already admitted to various medical wards.
Last week end was reasonable. Only couple of very sick patients who ended up in the ITU(intesive treatment unit). Our ITU is very top led. I see the patient if he very sick and I mean very sick, has a good quality of lif previously, then I call the medical consultant on-call who then takes all the details from me and call the ITU consultant on-call. ITU chap then either comes down himself or sends his registrar down. In other hospitals I've worked in it is usually a registrar to registrar affair and we usually let the consultants involved know what happened. Here there is a rigid system. Helps ITU weed out admissions I guess. But it is a pain in the butt to go through the convoluted system.
The worse thing about weekend duty is week afterwards. Because you have done 14hrs every day for 3 days in a row, the next week becomes one long drag. In essence you work continuously for a fortnight. European working time directive means that it is not as bad as it was previously. I still think that if you are a junior doctor you should be working more than 48 hrs. Perhaps not as long as 80 hrs, but 55 hrs seems reasonable. Controversial.
I will rant about about absence of adequate personnel or bodies on the ground during the week end and especially bank holidays, one of these days.

Summer and waste

Sitting in out-patients today. Slow day, lots of DNAs - 'did not attend' for the non-cognoscenti. Good weather outside, so lot of people didn't turn up. Result doctors and nurses sitting twiddling their thumbs. Lot of money wasted. Waiting lists get longer. Some hospitals and GP surgeries have suggested introducing a charge for non-attendence, ie. you pay upfront before the appointment day, if you turn up you get the money back, othewise you don't.
Seems like a good idea, however if you read the book Freakonomics then you may not be surprised if the opposite happens, especially if the charge is nominal. Logic according to the book goes like this - if you don't turn up, most people would feel guilty and hence will try and turn up, if you introduce a charge, guilt is expiated and hence less incentive to turn up. Or in layman's terms - reverse psychology. Introduce a hefty charge and you risk protests and also will target people with genuine reason for non-attendence.
No easy solutions.

Scrubs makes internal medicine cool again

Internal medicine had always been the less glamorous of medical specialities, especially compared to surgery. All those soaps featuring cardiothoracic surgeons, neurosurgeons, plastic surgeons - they are all about heroic surgeons.
Forget American TV, even British one are mainly about surgeons or A&E.
Now there are two medic centric ones - scrubs and House. House always makes me angry - outlandish medicine and even more outlandish residents who do everything from pathology to angiography. Nobody has heard of specialisation in House let alone subspecialisation.
Scrubs is my favourite medical serial at the moment. One of my young nephews now wants to do internal medicine - all due to scrubs. Couple of years ago all of them wanted to surgery, Scrubs has made it cool to be a medic again.

Bed cuts in NHS

Just read the news today that NHS has shed more than 30,000 beds over the last 10 years. As a junior doctor working in a busy DGH (District General Hospital to the uninitiated - ie. a secondary care hospital with some amount of tertiary care facilities), I guess I am in the front line of this unfolding disaster.
Our own hospital is buiding a new hospital which will result in loss of 300 beds when we move from the old buiding to the new one
To practise this bed cut, management has decided to close two care of the elderly wards resulting in loss of 60 beds in medicine.
Given that the hospital is already running at >95% bed occupancy, the logic behind this move is impenetrable. With average age of the punters coming in being around 75, closing care of elderly and rehab wards obviously makes sense!
Another reason being touted around is, with summer around the corner admissions will fall and hence if the closure doesn't lead to disaster, it can be hailed as a success and will justify further bed cuts when the new hospital comes up.
During winter we were opening temporary wards to cope with sheer number of sick people. Red alerts for bed status were the norm every weekend. With winter over we are barely coping with huge pressures to discharge early. Just how the hospital is going to cope in next winter is going to be interesting for me, as I will be moving to another hospital by then, but as you can imagine, hugely stressful for the staff here.
What all this does to spread of hospital bugs and patient care is a rant for another day.

Begining of a journey