Medically Fit…

Your mum is medically fit.

Jane is medically fit.

Old man Abe is medically fit.

Medically fit.

Can you be un-medically fit?

To be fit must a doctor be involved?

Medical fitness is a 21^st Century invention.

I am certain it wasn’t a subject covered at medical school, nor as part of the Royal College exams.

Who is medically fit, A, B or C?

You see, the big thing about being medically fit, is what it means in the context of modern-day medicine. It in effect translates as, ‘No longer needs to be in hospital,’ which, in the current world means, ‘Home.’

The problem arises predominantly for older people, when the gauntlet of ‘home’ is thrown-down within the hospital system. Home… Off you go. Taxi!

Because of the pervasive, overwhelming protectiveness and, likely, defensiveness of the NHS, ‘home’ doesn’t always mean, ‘home’

Home, but you are not felt to be safe to climb up and down your stairs, home, but you cannot wash or shave or put your clothes-on in an acceptable time-frame or manner; home, but you sometimes trip, stumble or fall on the way to or from the kitchen or living room.

Home, is grey.

Home and medical fitness are ideals. Pickett fence and apple pie.

Fall over, ambulance, A&E and, before you know it, tests and analyses, capacity assessment, tricky questions about competency, who is the Prime Minister, where are you and, which war is currently being fought in the Middle East?

We don’t make it easy.

And medical fitness is a little like a golden fleece.

Un-fit and the social workers and discharge folk can’t touch you. You can relax. Lounge in your hospital bed, enjoy the scenery. When medical fitness approaches, when it is written in your record, the process of detachment begins, Bowlby would have a hay-day.

And yet, my mum, she doesn’t seem right, she is still losing weight, unable to walk or toilet herself, she has a cough and occasional pain in the chest, how can she be? How is this fitness?

One man’s fitness is another’s morbidity.

Stability.

Not in imminent decline.

No need for thermometers and blood tests, or special manoeuvres to change your position in bed. You are your own person, society, or ‘the social’ takes over.

But… my mum, she doesn’t seem right.

Yes, your mum is dying, but, she doesn’t need the hospital right now, she doesn’t appear to be in the last days or weeks or months of life, she can keep on going for a good while yet, just, not here, not on our watch, on our hourly rounding or observations.

Let’s move forwards.

No good comes of hanging around, lingering in one spot.

Chick-chack.

Let’s go.

Ondalé!

26 April 2017

DToC

Most readers of my blog will not have heard of this term. I suspect most of those working inside the NHS don’t know of its existence either… DToC – Delayed Transfer of Care.

This is how groups of mostly older people are categorised once they are deemed medically fit – (another NHS neologism which too readily induces objectification), before they go home.

I know the people who invented (discovered/created?) this term probably didn’t intend for it to be used in a negative way – a little like Alfred Nobel and TNT; you think-up something novel, a new way to consider the workings of a system – even a person-centred interpretation of what it is to be prevented from getting home from hospital and suddenly it becomes a weapon, where the person is forgotten and the process (usually called pathway) takes-over.

Delayed Transfers of Care (I really can’t cope with saying ‘DToCs’) happen, in hospital, when a doctor deems a person fit for discharge. That is, in the eyes of the hospital, or the clinical team, there is nothing more that can be done to improve an individual’s health or wellbeing – indeed, the longer they remain in hospital the greater the likelihood of harm from all the risks of being somewhere you shouldn’t – medicalization, over-diagnosis, over-investigation, falls, hospital acquired infection and so on.

From the point the doctor says ‘MFFD’ (Medically Fit for Discharge – another term I don’t really like), the clock starts, with discharge teams, collaborations of health and social care, management and pathway staff rushing around in flurries of waiting times, lists and numbers to ensure that the usually older person is moved out of their hospital bed as quickly as possible.

Sometimes the next step is a discharge lounge – a sort of transient Neverland between hospital and home, or rehabilitation, intermediate care or step-down bed – alternatives which are a little longer lasting but just as discombobulating to older people, particularly those who have delirium, dementia or cognitive impairment:

‘Can you tell me where you are?’

‘Hospital’

‘No, actually we are in an off-site Discharge to Assess (D2A!) care facility somewhere in the North of England.’

‘Oh’

The reason some people have begun discussing Delayed Transfers of Care (which on reflection is a bit of a mouthful), is because of the Tory government’s crippling squeeze on social care – councils across the country having millions of pounds taken from their budgets which is an indirect cutback on healthcare; I know this sounds cynical – it is hard not to be a cynic when people are dying in hospital instead of living at home.

Because of this financial emasculation (too extreme a word?) of health and social care, older people are stuck in a limbo between hospital and home, with the delays becoming DToCs.

‘You are experiencing a DToC because there is no room in the intermediate/ rehab/ interim care/ step-down facility.’

You see the problem?

The person slips from experiencing a DToC to being a DToC.

You can spend lots of time and effort re-educating staff on the meaning of a word – for example, DNACPR – Do Not Attempt Cardio-Pulmonary Resuscitation, which does not mean ‘don’t treat/care’ – just don’t defibrillate or chest compress, or you can change the word and then work on the grammar, terminology and meaning later.

‘I’ve come to visit my dad, you know – bed six’

‘When is the next appendix?’

‘How many DToCs today?’

I don’t really have an answer to this, beyond a new government who doesn’t interpret balancing the books as screwing the sick, old and disadvantaged; in the meantime, perhaps, we can collaborate on finding a workaround to DToCs and a better way to keep the patients and staff people.

13 December 2017

Medically fit – today and tomorrow (3)

You hear this term all the time nowadays, at least, if you work in an NHS hospital, are an inpatient or carer or relative of someone who is occupying a hospital bed.

Most often…

Are they medically fit?

When will they be medically fit?

If they are medically fit, have you done the take-home medicines?

And so on, you get the idea.

It is all to do with the proximity of the patient – person – usually older, but not always, who is occupying a hospital bed and their exit from the ward/unit/department – this in turn will allow for another patient/person to swap places and allow flow.

Flow is another word that has become bastardised by the NHS.

Flow in its original form as described by Mihaly Csikszentmihalyi is a state of mindful occupation where an individual exists almost outside of time and space in a bubble of creativity or doing.

Flow nowadays is how many patients are moving round the micro (hospital) or macro system (entire health and social care network).

Critical to flow is medically fit.

Too many people who are not medically fit, and you have a problem. People keep arriving at the front door and not enough are exiting stage left. Things become crowded.

It is funny. Just a few years ago we used to talk about hospital bed occupancy; there was considered to be an optimum level – somewhere in the mid 80 per-cents, which allowed for flexibility, accurate and appropriate allocation of patients to specialist areas, now, the system only exists at something like 100%.

Like the rush-hour Tube – bursting at the seams, the last person squeezed-in as the doors shut.

An overflowing train may help move people, it might even earn Virgin Trains lots of money, it isn’t however much fun or pleasant for the folk who are knackered, leaning against the toilet door on the six-o-five from Paddington.

We know the reason for the obsession with medical fitness (which I don’t think I have explained, but, you can read more here and here.) – it isn’t that there are not enough hospital beds (although some people would disagree), it is not that the system isn’t slick, effective and efficient (after all, isn’t that the essence of the NHS?), it is that we have lots and lots and lots of older people who have nowhere else to go when they fall or become sick.

And, you ain’t seen nothing yet, as Bachman Turner Overdrive might have said in the 70’s.

The baby-boom generation are still babies. Still young, fit, healthy, vital. Leading independent, productive lives, net contributors to society and the economy.

Take a seventy-year-old, make them 90 add three or more long-term conditions… diabetes, arthritis, dementia, cancer and, you have someone who is potentially frail, existing in a precarious state where the health and social care system has a greater impact.

This is the world of today and will be the UK in 10 or twenty years.

The system is not coping now, how will it manage tomorrow?

Again, there are likely enough hospital beds, it is what is before and after that is inadequate – an older man who falls, bangs their head and can’t get off the floor. This happens all the time, countless times every day across the country. The system often struggles. The standard –

Fall alarm > paramedic > hospital

Breaks-down as the fingers of medicalisation examine and dissect the man, checking his blood pressure and oxygen levels, scanning his brain and testing his urine, the encroachment of a disorganised health and social care system reverts to what is best for the system and risks a flip to ‘not medically fit’ with pyjamas, lost dentures and more investigations.

And, that man who fell, becomes trapped in the flow, moving around a system which is under extreme pressure, and, as with all pressurised systems, the risk is that he will become first systematised, then crushed. Boxed-into a diagnostic formulary and processed.

And the systems that perhaps overzealously brought that man to hospital, despite their usual, although variable efficiency, will break-down when we try to find somewhere for him to go, now that he has acquired a urinary catheter, delirium, hospital acquired infection and increased dependency.

Is he medically fit?

Home? Intermediate Care (Neverland)? Care Home? Rehabilitation?

You see the problem?

He probably can go home, but, the issues that were present before he arrived at hospital, that potentially led to him falling at the outset are still evident – loneliness, social isolation, lack of community.

He sits in his chair, smiling carers, not necessarily focused (or, obsessed as they should be), with his wellbeing popping in an out.

We didn’t evolve to be 90 and sitting alone for 22 hours a day.

We didn’t probably evolve to live to 90, but, that is where we are, we are unlikely to develop a healthy adaptation to a solitary existence which would kill us when we are 40 or 50 years old.

Strip society of community, every person for themselves, Right-Wing dogma and you are left with this fragmentation.

Are they medically fit? They were never medically unfit – they were just socially isolated.

I sometimes think back to my mum’s last months of life, where she was supported in an amazing care home in Glasgow.

My mum, the inveterate talker, the person who thrived on social company and interaction, who found new friends for the first time in years after a slow deterioration from the isolation of living alone.

Were my mum to be within the system nowadays, for all the improvements, all the realisation that person-centre care is the only meaningful care, she would likely have been swept-up in the drives of efficiency to maintain independence (no matter how little was possible or desired), she would have moved or been moved around health and social care, flowing, probably unhappily, becoming more disorientated with each transition, until eventually all options were exhausted and she would be left with care. That is, long-term care, the Holy Land.

You see the disconnection?

Medically fit, pressurised bed occupancy, older people trapped in systems that don’t work and there you are, lonely.

We are social creatures.

Aristotle, quoted by Nietzsche said that to live alone one must be either a beast or a god… well, you probably better add the growing numbers of older people to that list, for that is the picture.

I hope this hasn’t been too gloom and doom, particularly for those of you reading this on Saturday morning, where here in Doncaster the sun is shining.

We are doing great things locally to redress this imbalance, you can go here to check out more!

16 December 2017

Medically UN-fit

I seem to have written lots about the state of ‘medically fit’ – the reason for this being my eternal struggle to understand the term which is matched only by the population as a whole’s complete lack of understanding as to what it means.

As I have already covered:

‘I mean doc, how can I be medically fit when I am dying?’

I am not going to explore this further – if you are interested to read more, please check-out these blogs.

My aspiration is to demonstrate that my perception has altered.

As to whether this is a consequence of my current circumstances or, as is more likely, a fallout of the decidedly unhealthy health service in which I work, I can’t say.

Let’s face it, although we are living through times of unbridled prosperity, with the average lifespan increasing, infant mortality dropping, better treatments for stroke, heart attack and cancer, it seems that the demand on healthcare is increasing – a little like a child who isn’t satisfied with one Haribo, but wants the whole packet and, when that is finished, the box.

I guess the words are inexhaustible, indefatigable and insatiable.

(Thank you Scrabble and Lyndsey).

How do you square the ever-growing need with the fixed provision?

The answer is, you change the terms of engagement, you alter the perception.

To start, you get rid of certain fixed ways of thinking that don’t help (and, we know, as thought follows language, we must begin there).

Tell yourself ‘I am crap/weak/angry/happy/sad’ 200 times and what do you feel inside?

First, I’d suggest we get-rid of the concept of ‘medically fit’ (for discharge) as, it is increasingly redundant.

I remember years ago, a senior doctor trying to convince me, a medical student at the time that the average number of legs was 1.9 – because of all the people with amputations. He succeeded for a while.

The average hospital inpatient is never medically fit – not in terms of their complete, holistic mental and physical health and wellbeing.

When was the last time you saw Usain Bolt in a hospital bed? (admittedly, although I am sure physically he is pristine, I don’t know what is happening in his head or soul).

The arbitrariness of fitness has to go. We are all at a certain point on the continuum of wellbeing, some less than others – with every existential positive at one extreme – joy, happiness, laughter, comfort, security, belonging, rest and, at the other, well, dead. (Unless you consider the states of being which some will argue are worse than death, although I don’t profess to know – there is an old bloghowever).

Perhaps I need a thought experiment…

Monday morning, before, during or after the ward round:

‘Who is medically fit?’

‘No one.’

‘No one?’

‘No one.’

The conversation will not end there, but you get the picture – a nonsensical game of ping-pong between consultant and discharge nurse, manager or co-ordinator.

‘You mean, there will be no one going home, no empty beds for new patients?’

‘Well – that is a different question, let’s talk…

We need to change the lens to determine who must be in hospital, after all, despite the work to make dementia and patient friendly environments, most folk still prefer to be at home. (Mallard Ward excepted).

Change the conversation – ‘Why is your patient in hospital?’ Or, better still, clarify with the patient, ‘Do you know why you are in hospital? What do you think is happening?’

Many people exist in a state of limbo based upon medical platitudes… ‘We are sorting things out.’ (What things?), ‘The physiotherapist is going to see you.’ (And what miraculous intervention will they make?), ‘We are waiting on the MRI report.’ (And, why wait, why is the report, or the scan not instantaneous?)

You see the point?

We have a hospital crisis when most of our what are perceived to be acutely unwell patients could be managed, supported or cared-for at home or, in the circumstances of the most frail and vulnerable a care home or facility.

Instead people sit, de-conditioning, acquiring infections, pressure ulcers, falls, depression, loneliness, losing important skills and abilities: ‘Nurse, I need the toilet.’ ‘Here, use this bottle/commode/bed-pan.’

Part of the failing relates to the pressure.

If I have 30 patients to review and treat in one morning session, I will spend half the amount of time problem-solving had I 15 patients, with more emphasis on plugging the gaps, papering-over the irregularities, the predominant symptoms and missing the point.

To address this superficiality, we use teams who support the delivery of care, but, often they are so pushed they apply an equally ineffective balm, moving-on or being called-on to the next crisis or situation.

We are running so very fast on the wheel that we don’t realise we are not actually moving or getting anywhere, other than exhausted.

So, time out. Slow down.

Pause.

Instead of five minutes skittering on the ice, let’s change our footwear, sit down and get to basics.

Does x need frequent observations as they might collapse?

If they collapse, isn’t that the 96-year-old’s prerogative?

Does x need long-term oxygen?

They smoke… Well, let’s talk about our intentions.

Does x need multiple administrations of intravenous antibiotics?

Are there any bacteria around?

Do they really need blood tests every day?

Were yesterday’s bloods different from the day before and the day before and the day before?

There are more situations than these, but, we could draw a list of the essentials of hospitalisation – who must be in hospital; Yes, those on ventilators, or, heart-lung bypass goes without saying – for the moment anyway (we used to think this of haemodialysis).

How many people would meet these criteria?

For how many could we find solutions that use the combined resources of community nurses, therapists, GPs, family and friends, heck we could even say to the hospital nurses and therapists – ‘You know what? Why don’t you go and see Mr or Mrs Y at their home? Get yourself some fresh-air!’

This was the model that was discussed years ago, it seems to have halted at an organisational hiatus where, like trams on the tracks we can only move in two directions; let us be like Daleks who, to contend with Christopher Eccleston evolved to cope with stairs…

‘I can’t see a patient in their home, I don’t have the equipment/resources/time/’

‘Fly!’

Inverting the model could be fun.

It will provide an extra level of challenge, but, not one that says the treadmill must run faster, but which seeks solutions from the bottomless pit of creativity, innovation and ideas that sit at the heart of every person. New, different, novel ways of approaching tried and tested problems, escape mechanisms we were previously too afraid to question.

I don’t suggest I have the solutions as each of them will be local, particular and person-centred; does the patient even want to have the operation? Where do their preferences sit in this relationship? What is in their best interests? What are their interests? Our patients are more than their GCS, Early Warning Score and urine output, what about the infinite complexity that is the human soul?

No, I probably won’t tell the bed-manager on Monday, ‘None of my patients are fit,’ as that might risk getting us both into trouble, it would also potentially end the conversation – ‘How many people must be in hospital for their treatment, care, support?’ Well – that is an altogether different question, let’s see…

27 January 2018

Unsafe admission

Yes, we all know the NHS is in crisis.

I don’t get the sense that people fully understand the enormity of the problem, but, there you go… Boiling frogs.

I have been reading recently about a concept I hadn’t heard of before – potentially unsafe discharge.

This is all an extension of ‘medically fit’ – the half-arsed notion the NHS uses to guide patients’ return home after a hospital stay.

It is a continuum – the patient moves from being medically fit to undergoing a safe discharge. The latter means you send the person home with the belief that they are not as unwell or sick as when they first attended – arrive with broken hip, go home with crutches, arrive breathless with pneumonia, home with antibiotics, this sort of thing.

All of this is also part of the idea that can result, when it goes wrong in failed discharge – this is when a patient is unexpectedly readmitted to hospital – officially, in the UK, within 30 days of them going home. Although, as with everything in healthcare there is more to it than that and, perhaps for another day, as I want to get back to the discharge process.

Going back to the crisis I mentioned at the start, the corollary of this is people going home who are less and less fit; I think back to the 70’s and one of my favourite sitcoms – ‘Only when I laugh*’ – the idea being, the wound/stitches/injury only hurts when I laugh, and, the joke, you shouldn’t be laughing in hospital, with the irony that none of the patients are that unwell and the further twist being the concept that in hospital people are sick and shouldn’t be too happy – which of course we know is wrong; just because you are old/ill/frail/infected/whatever doesn’t mean you lose your sense of humour.

(please excuse any double negatives in that last paragraph :-))

Anyway –

Most hospital inpatients these days fit into three broad categories –

Those who are very sick – who, without 21st Century care might die prematurely

Those recovering from being very sick

And, all the rest, most of whom are older, with multiple co-morbid conditions.

This latter group are usually the ones in the category of medically fit who are stuck waiting for physiotherapy, rehabilitation and most painfully social care – home care, care home, that sort of thing.

Again, I am going off-piste;

It is mostly accepted that we should aim for medically fit people who receive safe discharges. In this age of austerity, what is medically fit has been mutated into what might have been considered medically-unfit and unsafe discharge ten years ago.

And this too is not my point.

Where I am trying to get, is the start of the whole process, which relates to the other side, of the end-game – discharge; it is the concept of hospital admission – the notion that it is far easier to be admitted to hospital than it is to see your GP (although, I concede admission these days is harder than it was five years ago, with significant national variation).

It is relatively easy to enter hospital because most frequently the services at the front-door i.e. A&E, aren’t strong enough owing to inadequate links with community services or the pressure of less concrete concepts such as social isolation, loneliness, frailty being so great.

The example being:

89-year-old woman, lives alone, dementia, diabetes, COPD, has fallen, bruised face – best admit.

And this is the thing. This is the nub.

This is the polar opposite of an unsafe discharge, it is an unsafe admission. It is where the pressures, the demands – our friend the four-hour wait, influences decisions and instead of stepping back and looking at the situation as a whole, we focus on the tiny elevation in blood pressure or white cell count and translate this into, too unsafe to go home, not taking into account the potential harms that this can cause –

Loss of identity, disorientation, hospital acquired infection, falls, immobility, incontinence, pressure sores, dehydration, malnutrition, drug errors – the list of possibles is long.

Some hospitals have this sussed; creating frailty services that try to intercept the older people at the front door and reverse the unsafe admission; this is a growing movement and not embedded in all hospitals, nor is it the universal experience of all patients who might benefit – the current, dominant model of care being high-tech, acute medical, single-organ based, CT scan, take pictures and ask questions later practice. Nationally we have invested in acute services rather than services for older people, this latter effectively being what acute services are, but not everyone has woken-up to.

So –

The challenge.

Consider both unsafe discharges, don’t send people home too soon because of the pressure of beds, only to have them deteriorate and return in a worse condition five days later, equally, do everything you can to avoid one of the worst things that can happen to an older person – unnecessary hospital admission.

*Memories of dad, papa, Ivor and Harry playing 40-down, round the dining-room table on Monday nights, me pyjamas, dressing gown, warm.

**Remember when they used to wrap Lucozade in cellophane? Back in the days when it actually contained sugar!

10 March 2018

Beds (or bust)

The theme at work for this week was beds. Beds in the hospital. The pressure to empty them of well (‘medically-fit’) patients and fill them with unwell (sick) patients.

This happens across the UK, every day of the week. Indeed, it is probably taking place now (7am, Saturday morning) at your local hospital, large or small.

A constant, incessant, remorseless pressure to move patients – aka people, through the health and social care system.

You couldn’t imagine a more difficult ask.

You can keep traffic flowing on the M1 by adjusting the speed, number of lanes and rapidly addressing any blockages or breakdowns. In hospital it is a little different. In hospital we aspire to person-centred care, this means regarding each patient as an individual with one-on-one needs, demands, hopes, aspirations.

You can’t bulk-up the patients into ‘the traffic between junction 30 and 33’ type thing, imagine you had to look at each car, each motorist and adapt the conditions because of them.

Sometimes, to help people cope, the patients are substituted not with people but beds; move this bed here and that one there and create capacity to accommodate another. This is a little like the depersonalisation that happens with the traffic. I am not being critical of those who do this – it is out of necessity – it is cognitive dissonance generated to preserve their humanity. Objectification.

I have written before about bed capacity – the need for the system to have slack to operate – this is somewhere about 80% bed occupancy; the NHS over this winter has been running at 95 per cent – and, when you consider that is an average taking into account day-case and paediatric beds, the true number is something like 110% – that is, more than one person occupying one bed each day.

They call this hot-beds on submarines, where three different people sleep in one bed, in shifts.

The next stage is bunking-up; sleeping head to toe.

Within the maelstrom, this craziness are the patients, their carers, family and friends and the staff.

The staff are run ragged. Torn apart by unremitting pressure and demands; compassion fatigue; you’ve all heard of that, no? That is when you start with a kind, loving, caring, considerate person and take and take and take, you knock the compassionate stuffing out of them, you allow no time to recover, shift after additional 12 hour shift, combined with physical and psychological exhaustion and, you have a person who is just concerned with getting to the end of the day, not necessarily holding the hand of Enid in bed 13. Anyone can be affected. I have been. It isn’t pleasant.

Well, Rod, how do we remedy this pressure? There must be an answer, a solution, a way-out that we haven’t considered?

Again, across the UK groups of people are coming together to establish ways to understand the movement of patients, thinking-up ways in which we might work together collaborate (as Don says) – create a Team (the only way individuals can meaningfully increase productivity).

Folk are left scratching their heads.

For some the answer is straightforward.

Stop medicalising. Keep loneliness separate from medicine, co-locate, concentrate the super-specialists, up-skill the unskilled, patchwork cover, stretch the hand-towel in an attempt to maintain your dignity. Contort, make yourself small.

None of this is working.

You hear of centres of excellence. Places where is it going just fine. Many of those are a sham. An attempt by people to construct a picture of success, ever hoping for progress, a better tomorrow; and, for every Salford or UCL there are multiple locations where people are not even aspiring to talk positive.

The government is screwing the NHS through mismanagement at every level and this is left as the elephant in the room. Think of a grey animal. Yes, think of a struggling system.

It’s not that people haven’t tried to say there is a problem, to challenge the direction; heck, last year, junior doctors were on strike, picketing hospitals. That seems to now have been forgotten. Now, we are caught-up with a deterioration in the system where too few doctors are trying to care for too many patients, the same with nursing and therapy. And, instead of spitting on the health secretary’s polished patent leather shoes, we harangue the managers, who in turn sigh.

I hadn’t intended this to be negative.

It is hard to talk about the NHS, patients and hospital beds without this being a theme.

I guess, my aspiration was to bring the conversation round to the problem; the collective challenge. No one is sitting pretty. This affects us all. You, your children and parents. It will affect them at the least expected moment. We are all in the game. We can all, at the flick of a switch (of metaphorical fate) become a bed, appendix in bay three bed four.

None of us want this, none of us aspire to this, yet, it is the direction of travel.

Any answers?

17 March 2018