4-hours

I attended a big NHS conference today in Leeds – there was lots of discussion around ways to improve the care system, particularly approaching next winter (16 weeks to go, apparently).

I caught-up with some friends I hadn’t seen in a while and altogether it was fun.

Interestingly, two of the people I spoke with, when I told them about my recent move to Rotherham, didn’t specifically discuss niceties about how great it was I had a new job, or anything like that; no, they said – ‘Oh, I’ve heard they didn’t do very well on their four-hour wait.’

I wasn’t sure how to respond to this, so, on both occasions I shrugged, felt a little embarrassed and changed the subject.

Looking-back it was kind of weird. I later-on asked one of the Rotherham folk about this statistic; it seems, although our waiting times are not fantastic, they are about average; nothing to be ashamed of.

Perhaps it was the venue that brought-out this behaviour; we met in Elland Road where chart and league obsessives calculate team positions, relegation and promotion.

I’d never really considered healthcare as a competitive sport.

I guess I have it wrong.

There are of course league-tables for hospitals, those with better or worse performance, infection rates, financial balances and so on.

It isn’t really a level playing-field however.

Some places have more young people, others are more affluent, some a higher measure of deprivation, comparing like with like is fraught with inconsistency. Added to this is the way the data is represented and communicated.

I remember a few months ago hearing about a local organisation’s data relating to discharge rates – although certain people had been in effect showing-off their data – demonstrating how great they were on a certain measure, it was only when one of their nurses revealed what was underneath the data that the true picture was revealed. (It was the statistical equivalent of hiding patients down the back of the settee).

For example, hospital A may have a very long waiting list for an operation; if hospital B has certain processes that exclude patients from the same operation, despite in reality having a longer list, or fewer people needing treatment, their actual wait may be longer – what is revealed can be a misrepresentation.

You might expect there to be harsh penalties for organisations submitting dodgy numbers to monitoring bodies – the problem however, is, each system and organisation is so different that like is very often not being compared with like.

My apples/your pears kinda thing.

This was something I talked about a while ago in relation to pressure ulcers.

On my ward we were counting pressure ulcers – we had a great track record, then it happened that a patient developed a sore. Now, very occasionally harm will happen to patients despite the best intentions of staff; someone might fall, even though all reasonable measures have been taken, so too with ulcers, a patient may refuse to change their wet pants or get out of bed or their chair, this when it leads to a breakdown in skin is called a pressure ulcer.

Is it reasonable for this statistic to impact on the very good figures (and potentially morale) revealed by the ward or team, to take the 1000 days since back to zero for something that is outside the control of the doctors and nurses?

To this end, the concept of avoidable harm was developed, with the patient who refuses to comply with guidance and support, not because they are unable, but because they make an informed choice, not affecting the figures.

So, you can have 1000 days since unavoidable pressure ulcer or 30 days since pressure ulcer. This is semantics, and to some extent akin to this morning’s blog about the elderly and frailty (gad, I am predictable am I not?!)

When you get down to the nitty-gritty of who is fit, who is medically fit, who needs hospital admission, who needs an assessment or review, the complexity grows.

Superficially, the government’s target of a four-hour wait is a good thing; it suggests that people should not have to wait more than four hours for treatment; underneath this however are all sorts of implications. Should someone who could have gone to see their GP or perhaps taken paracetamol and stayed in bed warrant a four-hour wait? Should the person who is critically ill have to wait? Doesn’t clinical need mean anything?

And, in particular, is life not hard enough, without all the pressures of moving people around health and social care systems to tick target boxes a little silly when all of us are so stretched anyway?

So, the funny thing. The anomalous four-hour statement.

This is not data I carry with me. (Anyone who knows me, know I am not big on data) It doesn’t help my old lady get home from hospital, it doesn’t support my patient to live well and independently; it is just murk that colours the sedimentary intentions of good people working in difficult situations.

I am not sure how I will take it the next time I am advised about the good or the bad of the four-hour wait; I might reply, ‘I know darling, isn’t it fantastic!’ in a Kenny Everett/all in the best possible taste accent; I might run away screaming, or I might employ one of my diversion tactics… ‘Would you like a cup of tea?’