Thursday, 13 March 2008

"There is a 3:38 in Bay 5"

Having spent a few days in A+E, it is already immediately obvious what the most important thing is. Wouldn't you think that in 2008 the central focus of care in the A+E department would be the patient? It isn't the nurses' fault, nor the doctors', both of whom work very hard to ensure patients receive the best care possible, but there is something more important on their minds. What can be more important than the patients I hear you cry with horror? I'm sure most of you have guessed by now: the 4 hour target.

The 4 hour target effectively means that all patients presenting to A&E, regardless of what is wrong with them, must be seen, assessed, treated and shipped out (either sent home or forwarded on to another department) within 4 hours. This might seem like a good plan, and well, it is wonderful that nobody has to wait for more than 4 hours before they see a doctor, but unfortunately every patient is different. You can't shoehorn all patients with their vast range of problems into the same 4 hour bracket. Things just don't work like that in real life.

Sometimes it is easy to see, assess and treat patients within 4 hours. But in a fair number of cases, and particularly on a Friday or Saturday night, this is simply not possible. Or rather, it isn't possible to assess patients properly and provide the best possible care. It really shouldn't matter how long it takes, it should matter that it’s done right!

Patients are no longer known by their names, or even by their conditions any more. At best they might be known by their location – “bed 5” - but more often than not patients are referred to by a very special number. This number tells you how long they've been in the department. Displayed prominently on an electronic whiteboard is a list of all the patients currently in A&E and waiting to be seen, and the second a patient ticks past a 3 hour wait, their name lights up like a Christmas tree in bright red. If their stay approaches 3 hours 30, then the managers start to appear from their hidden lair (where I imagine they must watch intently the time spent in A&E by each individual patient). Of course they don't actually care in the slightest about Mr Jones who is having a heart attack right there in the department. The fact is, they are there to remind you that he has got to go. Wherever it may be. As long as its not A&E, and as long as it's not their problem any more. If you even mutter the word 'breach' (the description of those who miss the 4 hour target) in the vicinity of the A&E department you'll either be shot, or smothered in managers eager to find out what you know and what they can do to stop it.

In my few days in A+E I've already seen patient care put at risk due to this target. To me this is ridiculous, in fact, it's beyond ridiculous, it's dangerous. I imagine this target was thought up by someone in an office somewhere who'd not been near an A&E department since getting a little too drunk one night during their Philosophy degree. That is the problem with these things, they're dreamt up by people who haven't the faintest idea about how they will work in real life. Targets, targets, targets is all anyone seems to care about these days, forget the patients in hospital, they don't matter. I'm sure it makes wonderful headlines and prodigious soundbites for the government. Which voter wouldn't want to see "A&E Waiting Times Down!" plastered across the media? And there we have it, as much as the government, it's the fault of masses who demand reassuring statistics and some of the media, who leave only a few huddled words below a headline that hits the reader between the eyes. We need our journalists, and the voters, to look beyond headlines and ask, “waiting times might be down, but at what cost?”


Jason said...

Why does it have to be a politics student from Oxford, bit of regional prejudice getting through there you northern oik? ;D

missbliss said...

Oh sweetheart, you really need to let me wave my punctuation wand before you post :p

Targets, headlines and soundbites. There is no concern for a job well done any more.

Garth Marenghi said...

top notch ranting, keep it up!

PhD scientist said...

Crikey, fame at last LM - links on Dr Crippen AND Dr Rant, that's big league stuff.

Of course, the other thing that has ensued, apart from "4 hr wait managers" is expansion of MAUs (Medical Assessment Units) like the one where Mrs PhD Sci used to work. Patients could be shunted to MAU if they were still waiting on medical work-up but were in danger of breaching the 4 hrs. That's not the MAU's only role, of course, and a lot of people agreed it was better complicated or "more extended obs needed" patients be sent there than (inappropriately) admitted to specific medical or surgical wards. .. However, Mrs PhD Sci's MAU did used to have repeated fights NOT to get clearly inappropriate "turfs" from A&E. These were typically patients who were highly likely to end up being sent home from A&E but whose assessment was going to end up taking marginally more than 4 hrs.

It is difficult, though - the problems the A&E CN points out over at Dr Rant are real enough, and one used to hear enough stories from three-drinks-aboard Drs. So the target and money-or-no-money as per target system addresses one problem, but causes a whole load of others. Modern command bureaucracy in a nutshell.

The solution in Europe (at least in France and Germany) is to have more GPs AND community based specialists to "deflect" demand from A&E and hospitals; then people who do go to hospital get seen quicker as there are less of them (patients). But they do spend a lot more in those countries than we do.

Of course, the nonsensical "gaming" in the present UK system is an endless topic of conversation at the medical dinner parties I sometimes attend w Mrs PhD Sci. One classic gag was about the week a yr or two back when the A&E Dept waits got audited country-wide. As I recall, a later survey found that something like 97% of all hospitals with A&E Departments had put on lots of extra doctors (presumably on time and a half) and extra other staff (ditto) for the assessment week (the dates were known well in advance).

When this "97% of hospitals gamed the target" figure came out the standard dinner party gag was (dead pan) "Only 97%...?"

Mousie said...

You're obviously having the same kind of week I am!

Anonymous said...

Apologies, apologies

I put "her" ....

... I meant "him"

Have corrected.


Calavera said...

I know, I have heard many Emergency Med consultants complain about this. The worst thing is, is that all it does is lowers staff morale and encourages staff to find shortcuts and 'cheats' out of this stupid target, which may or may not be in the best interests of the patient.

Sad, really.

Anonymous said...

Humanities students are usually responsible for most things but no self-respecting Oxford PPE-ist is going to leave his law firm / investment bank to lurk around a hospital. Maybe that's the problem.