Although it was weird at work today, what with the snow and various unanticipated clinical events, yesterday was odder still – much of it starting with an encounter I had with one of the trainee doctors.
‘You know, Dr Who,’ I asked.
‘Doctor Who – you know, off of the TV.’
‘The space and time-travelling guy?’
Remember, I am not English…
But… Dr Who – he’s international; the guy with the blue police-box, the alien time-lord?
I was trying to explain to my colleague – let’s call him Sam, about my three-heart model of acute hospital care; (don’t worry, I’ll get there…) – and, my strategy, or lead-up to this description was to begin with, Dr Who, who has, as we all know (except Sam), famously, two hearts.
‘The way I see it, is, that all acute hospitals in the UK have three hearts – all of which need to be healthy to maintain a functioning system of care and treatment.
Those hearts are the emergency (A&E), intensive care and the acute medical departments. You can do away with surgery, orthopaedics, maternity and things can work – yet, without one of the three hearts you can’t have any of the other specialties.
So – imagine, the three hearts pumping away. Those hospitals with healthy hearts are able to cope with the demands of 21st Century care. Support teaching and training, plan for the future.
Nationally, many hospitals are in a precarious state, frequently because one of those hearts is diseased; not because of badness, but, workforce issues and recruitment.
If you can’t recruit enough nurses or doctors to provide intensive care, the rest of the model is unsustainable; the same goes for A&E and acute medicine.
Different areas have different challenges. Some places struggle to find enough A&E doctors – there was a hospital which had to temporarily close recently because of this, and consequently, the other services fall; if you can’t support someone who is critically ill by having access to an intensive care service, you can’t run an A&E – and, if you don’t have enough ‘intensivists’ – who are usually anaesthetists, the model collapses.
What you find across the UK are two groups of hospitals. Those, usually the biggest teaching hospitals and district generals who have managed, often because of geography, sometimes because of culture to attract and maintain a critical mass of the different disciplines; they are managing OK.
The others are the smaller teaching hospitals and district generals, who often have to compete with the larger hospitals for staffing.
This creates an imbalance.
What is equally consistent across the UK are the demands of the acute medical service – that is, the hospital work-horses who see the majority of admitted patients (falls, infection, confusion). They are all working at capacity, with no room for additional patients or demand.
You might think it straightforward – take those hospitals that are teetering because of staffing, close them and put all the staff into the other hospitals and you have a sustainable service; the caveat however is the admission and assessment units, none of which can cope with a 40 or 50 per cent increase in demand; hospital bed occupancy in most acute hospitals in the UK in 2018 is somewhere on average around 95% – most commentators say that for a system to operate efficiently – there needs to be capacity, room to manoeuvre at around 75% – beyond this people work in a crisis mode, and inefficiency (length-of stay, complications, incidents) increase.
So, if the answer is not to close the smaller hospitals, perhaps the answer is to look at the giants. It is not uncommon to attend a large teaching hospital that has 30 neurologists, 20 geriatricians, 15 acute physicians, with an equivalent district general seeing perhaps 60% of the patients with ten percent of the consultants in the relevant specialities.
Some of this reduction in size is not a bad thing – it creates efficiencies, workarounds, a greater focus on team working and lateral thinking, with closer relationships between individuals, allowing for more person-centred care; yet, the pressure mounts and just like the bed capacity being at a certain level, the potential for those smaller organisations to absorb challenges – perhaps one doctor leaves, another is one sick and, you have a crisis.
What we need are healthy, sustainable systems.
We need a degree of equity with workforce planning taking into account the needs of the population as well as the challenges faced by the people who provide the clinical and support services;
The next time you are admitted or visit hospital, check the wellbeing of each of its hearts; they should provide you a good estimate of quality and outcomes.
Something to consider.
Perhaps those who sit in positions of influence should take this into account when planning for tomorrow.
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