NHS Code Black

[Tim Jones]

I'm personally unlucky enough to have to deal with Wexham Park Hospital outside Slough.

It's been considered inadequate for years on and off but sadly those responsible for planning have been incapable of resolving the issues.

The hospital staff are, in the main, caring and responsive. The administration however is dangerous - and that's no exaggeration.

This has been going on for at least the two years that I have been having to use the place. People in the area have no viable alternative. I know people who would rather drive fifty miles in a taxi to visit A&E than take their chances with this Trust.

This hospital is also in code black at the moment and waiting time in A&E is over six hours today. This hospital trust was once the exception. This no longer appears to be the case.

I think Heatherwood & Wexham Park are in the process of merging with Frimley Park. Time will tell whether this improves things (although management mergers on their own usually don't). It's an open debate as to whether particular managers in particular Trusts can or should be held responsible for failure because the reasons for that failure may be well outside their control. Everyone is in trouble, and they are in particular trouble when it comes to A&E because of the system's failure to manage complex older patients, and those with long term conditions effectively, such that they inevitably are sent to A&E for clinical reasons, or because the GP can't cope with them.

Meanwhile, because of a perfectly well intentioned brainwave a few years ago, the Trusts actually only get paid 30% of the costs of any A&E admission. You can see how this might be a perfect storm.

 

[doctorf]

I think Heatherwood & Wexham Park are in the process of merging with Frimley Park. Time will tell whether this improves things (although management mergers on their own usually don't). It's an open debate as to whether particular managers in particular Trusts can or should be held responsible for failure because the reasons for that failure may be well outside their control. Everyone is in trouble, and they are in particular trouble when it comes to A&E because of the system's failure to manage complex older patients, and those with long term conditions effectively, such that they inevitably are sent to A&E for clinical reasons, or because the GP can't cope with them.

Meanwhile, because of a perfectly well intentioned brainwave a few years ago, the Trusts actually only get paid 30% of the costs of any A&E admission. You can see how this might be a perfect storm.

Perhaps you could explain how GPs are expected to 'cope' with elderly complex patients? They are not fvcking magicians.

 

[Tim Jones]

Perhaps you could explain how GPs are expected to 'cope' with elderly complex patients? They are not fvcking magicians.

Don't take offence. I'm not saying they are. I'm saying they are just flat out of capacity to deal with clinical demand - perhaps because primary care is just expected to soak up so much.

 

[merlin]

I think Heatherwood & Wexham Park are in the process of merging with Frimley Park. Time will tell whether this improves things (although management mergers on their own usually don't). It's an open debate as to whether particular managers in particular Trusts can or should be held responsible for failure because the reasons for that failure may be well outside their control. Everyone is in trouble, and they are in particular trouble when it comes to A&E because of the system's failure to manage complex older patients, and those with long term conditions effectively, such that they inevitably are sent to A&E for clinical reasons, or because the GP can't cope with them.

Meanwhile, because of a perfectly well intentioned brainwave a few years ago, the Trusts actually only get paid 30% of the costs of any A&E admission. You can see how this might be a perfect storm.

They have been talking about being taken over since 2013 - there's a lot of citizens' health that's been put at risk during that two and a half years Tim.

In 2013 the Accident and Emergency Department at High Wycombe was closed.

There are nearly 200,000 people in Wycombe. Those using A&E were redirected to Wexham Park - 13 miles away - and Stoke Manderville.

The number of patients waiting for in excess of 4 hours went up from under 4% to over 20%.

All this at the same time as the population of the area is increasing at a higher than average rate given the iminant arrival of Cross Rail and it's proximity to T5 at Heathrow.

Being polite, it's surely not rocket science? I would imagine there are a number of school leavers who would look at the situation and say the domino effect of what was being done in Wycombe would be potentially dangerous?

It's not just A&E at Wexham though, it's the whole system starting with primary care. It's simply not possible for a GP to make accurate medical judgements all of the time based on 5 minute or 10 minute appointment limits.

A case in point a friend of mine recently had a case of coughing syncopy. He reported this to the doctor who, under time pressure, just gave him anti biotics and told him to take his athsma medications.

A week later he had another case, this time behind the wheel of the car he drove (ironically for the private company responsible for the out of hours GP service). He lost control went across the central reservation and hit a mother in a 4x4 head on - again ironically about 200m from the entrance to Wycombe General Hospital.

An ambulance had to come 14 miles from Slough. Luckily no one was killed (that was pure luck) but had the GP the time, they could have asked the questions they then asked at the hospital preventing further episodes.

Again, to those of us not in the service none of this is rocket science. If the funds aren't there, then I would simply walk out as it would be impossible to do the job I was being hired to do. That would be less dangerous to the public than making MPs believe that grand schemes like merging A&E departments actually benefit anyone other than the treasury.

 

[Tim Jones]

To run an A&E department, you need a greater and greater set of things to be present on the same site -ITU, lots of diagnostics, paeds, cardio, maybe even some neuro for trauma. And there's a recruitment issue too - docs don't generally like working in small hospitals, so you can get an effect where the Royal Colleges withdraw training accreditation. (Edit: journal report out tomorrow will confirm that mortality is better in bigger hospitals...)

At the same time, the debate about A&E needs to be tempered by the fact that ambulances are very, very far away from just being a vehicle that turns up and transports the patient. They are mini-A&Es in their own right who can stabilise just about anything.

I get the funding point - of course I do. But it's my (our) job to try to do the best with what we've got. In this context my point remains that we have to try to rearrange services (with least possible disruption) to better match demand. If your argument with the Chancellor is simply that we need to increase spending, I suspect he would ask of you the same things that I, and others, have in this thread.

I think that there is also a case this is also not solely about funding in the sense that our model of the NHS - GPs, A&E, etc, has not really, fundamentally changed since 1948. Nor has the workforce or the professions within it. And this, I think, has something to do with what patients experience - the being passed from pillar to post, the constant repeating of the same information on different forms, and the serious clinical risk of falling through the gaps.

International comparisons are interesting here. The Dutch, in particular, are much, much better at managing demand and patient outcomes in emergency care than we are, and not only because they have a different funding model.

 

[merlin]

I think that there is also a case this is also not solely about funding in the sense that our model of the NHS - GPs, A&E, etc, has not really, fundamentally changed since 1948. Nor has the workforce or the professions within it. And this, I think, has something to do with what patients experience - the being passed from pillar to post, the constant repeating of the same information on different forms, and the serious clinical risk of falling through the gaps.

That is why I made the comment about maybe changing the team Tim - the comment that caused such offence.

We've had thirty years of tinkering and we have an inferior service - not a superior one. For me personally there are fundamental changes that are long over due on funding, on staff contracts and on the management structure.

It strikes me that the civil service has been trying to make changes to the latter two for decades to poor effect. That was one of the reasons I asked you about points of reference when it comes to efficiency metrics - a question that has still to be answered. It's as is staff are being incentivized to do the wrong thing.

 

[Brian]

My issue with your criticism is that despite several attempts to get you to explain how you would deal with some of the fundamental issues I've outlined, you have failed to do so. There is little, if any clarity in either your diagnosis or cure. That isn't stifling - it's a perfectly reasonable request that you and merlin have consistently dodged, as noted by other contributors to this thread.

Your replies are suggesting my own posts are aimed at you personally, they aren't. Now you say something else. To clarify, I've posted no personal insults toward you so I suggest you give that accusation a rest.

As for your post quoted, there is no requirement for someone to have a solution when commenting critically on anything. After saying that, I did reply, you just didn't like it.

 

[Tim Jones]

The civil service does what it is told by the elected Government of the day. And to fundamentally change the model of how the NHS is provided is not a challenge that many politicians want to take on - and certainly not something that the BMA, the Opposition, the media, or an enormous host of other people would not put up an immense fight about. Added to this, the electoral cycle means that in effect we are only allowed to do difficult things in the first year or two of a Parliament. This blight is, if anything, getting worse.

I have (more than once) answered your question about efficiency, but I will do so again (because we may be talking about different things). In any organisation it is about the relationship between inputs and outputs. In the case of the NHS, the input is the cost to the taxpayer, and the output is about patient outcomes and population health. The hard bit is about using the former to maximise the latter, and the unsavoury choices that entails. Now anyone can wheedle around in this and I fully expect you to, but if your answer is simply to spend more money on what we've already got (which is all that seems to be on the table), then my questions to you about taxation and GDP become very stark indeed.

 

[Tim Jones]

there is no requirement for someone to have a solution when commenting critically on anything. .

 

[Brian]

Sadly for you though my earlier comment is correct, as much as you don't like being questioned.

 

[Mick P]

Tim

You can take a horse to water but .......

I would just give up, you are going nowhere with these two.

Mick

 

[merlin]

T
I have (more than once) answered your question about efficiency, but I will do so again (because we may be talking about different things). In any organisation it is about the relationship between inputs and outputs. In the case of the NHS, the input is the cost to the taxpayer, and the output is about patient outcomes and population health. The hard bit is about using the former to maximise the latter, and the unsavoury choices that entails.

Tim, my question re efficiency was more specific as I am sure you are aware. Your posts just really simply continue to state the obvious.

At what points does, for example, a neurologist at one health trust, have efficiency markers to meet? We know about the maximum delay for initial consultation marker. What about other markers that enable that department to meet its targets?

My suggestion (in the example I provided and have still not had a response to) is that the efficiency is being measured in the wrong place because segments of the service are being incentivized in the wrong way.

Now all I've had in return is suggestions that I'm insulting and that I am advocating unlimited budgetary increases - neither of which appears to be correct - hence my suggestion vis a vis politics.

Governments are not elected with the sole aim of getting re-elected and firming up their careers in Westminster. They are elected to make decisions that are the best for the majority of the nation's citizens. Electoral reform can also not come quickly enough but that is another subject.

The truth is that the government needs to explain that we need to spend more on health care and it is going to cost voters money. If put in the right fashion this should be trouble free in the long term. Difficult decisions don't have to be automatically abhorrent to staff and their representatives. Going in with that attitude can't help.

Mick. Uncalled for. As usual.

 

[Suffolk Tony]

One thing the NHS does not need to do is get rid of folk like Tim, and the many good managers who struggle to make things work. Because in the end, it's only through good management that the crisis in NHS services will be solved. A herculean task (just try managing clinical staff!) and they should be given every support. Please stop calling them "bean counters" and suchlike derogatory terms.

 

[jackbarron]

I have (more than once) answered your question about efficiency, but I will do so again (because we may be talking about different things). In any organisation it is about the relationship between inputs and outputs. In the case of the NHS, the input is the cost to the taxpayer, and the output is about patient outcomes and population health. The hard bit is about using the former to maximise the latter, and the unsavoury choices that entails. Now anyone can wheedle around in this and I fully expect you to, but if your answer is simply to spend more money on what we've already got (which is all that seems to be on the table), then my questions to you about taxation and GDP become very stark indeed.

Hi Tim,

I haven't bothered to take part in this debate for a while. I would initially say that Merlin's post, which set off the flack, wasn't full of ad hom. It seemed quite carefully worded to me.

You have asked me to supply the Labour solution on a couple of occasions. Labour say more money needs to be spent on the NHS, plus elderly and social care. I think you already know this. Labour plan to spend an extra £2.5 Billion more than the Tories each year.

Is the question about taxation and GDP stark in this proposal? I don't think so, you get what you pay for, there is no magic wand.

The extra money will pay for more doctors and nurses. It will also help to build up post-hospital services in elderly and social care, although I might be wrong about the latter, I'll have to check.

Corbyn says Labour won't use PFI to do this, which Blair and Brown did, because it has got the nation into a massive amount of debt. The taxpayers are forking out over £2 Billion each year in interest alone to private firms who are getting fat on it.

Corbyn wants to set up a fund to bail out Trusts from the PFI schemes, which have been forced on them. You can read about it here: http://labourlist.org/2015/08/jerem...fund-to-bail-out-nhs-trusts-from-pfi-schemes/

Meanwhile Cameron, Osborne and Hunt, are quite happy to keep using PFI schemes, well they would be wouldn't they?

Labour will raise money by cracking down on corporations and the rich to fund the NHS. Osborne's family firm, Osborne & Little, should be targeted. They have paid no tax in the last seven years, despite making £200 million, which is pretty outrageous. Labour would scrap the renewal of Trident, if they get the go ahead from the Party and voters, which would save £120 Billion.

What do you think about the Labour plan, Tim?

I reckon it is better to have more money, rather than less, when it comes to the NHS.

If anybody wants to know in detail what Labour's plans are for the NHS, they can check the following links:

* Labour's 10-Year Plan For Health and Care: http://www.yourbritain.org.uk/uploads/editor/files/Labour_Ten_Year_NHS_Plan.pdf

* Labour's NHS Pledge in its Manifesto: http://www.labour.org.uk/manifesto/nhs

* Labour's NHS Time to Care Fund: http://www.labour.org.uk/issues/detail/nhs-time-to-care-fund

There is plenty read. If you want to move towards a solution for the NHS, vote for Corbyn. What is happening with the NHS is a political problem, as much as anything else.

Jack

 

[Brian]

One thing the NHS does not need to do is get rid of folk like Tim, and the many good managers who struggle to make things work. Because in the end, it's only through good management that the crisis in NHS services will be solved. A herculean task (just try managing clinical staff!) and they should be given every support. Please stop calling them "bean counters" and suchlike derogatory terms.

I am not referring to Tim when I say bean counter, I have no idea of the fine detail of what he does, nor do I care. Are you under the mistaken idea I'm referring to all NHS managers, or are you claiming there is no bean-counting going on in the NHS?

 

[Mullardman]

Jack. Excellent post. #194.

I would only add that whilst the Tories bleat on about the cost of the NHS, we spend less per Capita than most comparably developed countries, with only Spain and Italy spending less.

I'd also ask why there has been such a dramatic shortfall in the last year or so.
Wage inflation is low, inflation overall is zero or less and I find it hard to believe that all of the cost pressure comes from the demographic changes in such a short timespan.

Something is very amiss.

Mull

 

[Tim Jones]

Hi Tim,

Is the question about taxation and GDP stark in this proposal? I don't think so, you get what you pay for, there is no magic wand.

What do you think about the Labour plan, Tim?

Jack

Jack - if I'm called upon by the elected Government of the day to deliver it, I will try to deliver it. Personally, I do fear, however, for your reading comprehension, as I do for Brian and merlin. I have tried, repeatedly to illustrate the dynamics in play here.

I can't help but imagine that all of you will be first in line to oppose anything that anyone tries to do to reform the NHS that doesn't automatically involve simply spending a lot more taxpayers' money on existing ways of doing things.

 

[Mullardman]

Tim, I'm trying to be nice here but I find that response (#157) rather 'haughty', for want of a better word.

ISTM that it behoves Govt. to do as Merlin states and explain that more taxation is at least a partial answer to restoring the effectiveness of the NHS. We spend less than other comparable countries. It can't be so difficult to compare this to the horrors of sinking into a US style system... surely? Unless that is the objective?

I also agree with comments to the effect that Govt. chooses to adopt measures of 'efficiency' which suit its political purpose. It does so with all other Govt funded organisations, so I don't see NHS being exempt. I've been a victim of this crude pseudo statistic-ising myself, both as an NHS 'client' and as a public servant.

Let me put it this way...

The population of my village has not increased significantly in 40 years.

The demographic has hardly changed.

There are now around 8 Doctors in the local practice, whereas there were three 40 years ago. There are now also phlebotomists, practice nurses, etc. etc. and around 4x more admin/reception staff than 40 years ago.

Yet getting an appointment to see any GP.. much less one who knows you.. is becoming almost impossible, and a home visit just won't happen, unless you are 'housebound'. I thought my wife was pretty 'housebound', by influenza and pneumonia, on top of acute gall bladder problems last Christmas, but ended up calling 999.

It's not good.

Mull

 

[Brian]

Jack - if I'm called upon by the elected Government of the day to deliver it, I will try to deliver it. Personally, I do fear, however, for your reading comprehension, as I do for Brian and merlin. I have tried, repeatedly to illustrate the dynamics in play here.

I can't help but imagine that all of you will be first in line to oppose anything that anyone tries to do to reform the NHS that doesn't automatically involve simply spending a lot more taxpayers' money on existing ways of doing things.

Ah, ad-hom aimed at 3 people now. Or at least no different to what you've been accusing others of being ad-hom.

Earlier on you claimed it wasn't political, in recent posts you imply it is, more than once now.

The NHS is apparently inefficient. Whatever has been happening to improve it has obviously been wrong.

 

[merlin]

Tim, I'm trying to be nice here but I find that response (#157) rather 'haughty', for want of a better word.
It's not good.

Mull

This is the problem. We all try to be nice but when pressed, all we seem to get is "I know best. Run along little boys" tinged posts rather than ones that answer questions posed in an intelligent and debatable manner.

The more Tim is pressed, the more this response becomes clear.

This is one of the reasons I suggested we might need a new broom. The political response and the inability to comprehend that others just might have ideas worth exploring are civil service issues that need to be resolved before national industries like the NHS can make a step change IMHO.

We are all trying to be polite here but I see an undertone that is mildly offensive in much of Tim's postings.