‘But, why do I have to go?’

These were the words I overheard recently as I was leaving work.

The scenario was a woman in her, early 40’s, sitting in hospital chair, being pushed from one ward to another. With her were two healthcare assistants.

‘The doctors know all about me, why am I being moved?’

‘You must be getting better now,’ the younger of the two women reassured, ‘How long have you been in?’

‘Three days,’ the patient replied, ‘No one told me, I didn’t know what was happening.’

‘We are always moving patients, to make room for new, you’ll be looked-after by the same doctors, don’t worry,’ the other healthcare assistant explained.

I was witnessing the process of outlying.

This it when a patient is deemed well-enough to slip-down the list who require close monitoring on a medical ward and can be supported somewhere else – often a surgical, orthopaedic or in the case of women, gynaecology ward – those areas in the organisation that are prone to ebbs and flows of patients, some elective, others emergency.

Cancel an operation and voila, capacity is created. This might lead to great distress for the patient who had been waiting for a hernia repair, but at least there is more room to accommodate an emergency.

Such is the game of cat and mouse that is played in every hospital in every town and city in the UK. The numbers of patients moved, and the pace of change is always at its peak in the winter when the numbers of older people with chest infections increases, and with this their length of stay.

It takes you more time (and cheyshek*) to recover from an infection when you are 90 than when you are 30. This is a fact of life.

I have written before about outliers. It has been an obsession of mine over the years. I haven’t yet discovered a system that works consistently well for patients, doctors and nurses.

Evidence suggests that every time a patient is moved between wards, they stay one day longer in hospital, two moves and the time doubles.*

Patients moving from ward A to B is a necessity of 21^st Century Healthcare.

Over the past decade things have improved tremendously – thanks to medical and frailty assessment units, a significant proportion of those who used to be admitted for several days are now supported at home.

When I was a house officer in the late 90’s, patients with a swollen leg were routinely admitted and started on intravenous anticoagulants with six-hourly blood monitoring, all with syringes often prepared by poorly trained junior doctors; I can remember scenarios where ‘query DVT’ was classed as an infectious disease (the possibility if not a clot, was infection) and such patients were transferred from Ninewells Hospital to Kings Cross, the then Infectious Diseases Hospital in Dundee.

Now all of this is done as an outpatient. In some areas you don’t go near a hospital bed; your GP gives you a tablet and you have a scan in the radiology department the same or next day.

Efficiency and effectiveness in the NHS have improved dramatically, yet, the numbers of patients continue to increase – some of this because of rising expectations and awareness (of heart attacks, strokes, for example) and often, because our society is ageing, and with age, comes disease.

Added to this, hospital closures and rationalisations of service have increased the pressure; poor planning of nurse, doctor and therapist training has left the UK with a workforce vacuum, we struggle to do more with less.

I won’t go too deeply into the politics, suffice it to say, the reality of ‘outlier’ is the reality of being a hospital patient. I don’t have statistics and it is likely that most patients don’t go through this experience, yet, the shift is so significant for an individual’s experience that the effects are disproportionate.

And, back to the patient.

I walked along the corridor, listening to her worries, eaves-dropping on the reassurances offered by staff and I thought to myself, ‘What a situation.’ (Stramash**?)

I don’t have any alternative solutions.

In pressurised systems, something has to give otherwise there is a pop.

Some hospitals have prioritised the care of outliers – seeing those patients first on ward rounds, not leaving them until last when the doctors are tired, and it is late in the day.

Some will question the wisdom of seeing the ‘well’ outliers over ‘sick’ base ward patients – there is no easy answer; and, frequently for those teams discharging patients from outlying wards, particularly at times of pressure, they are rewarded by receiving additional new outlier patients from other teams.

It becomes a little unfair.

And hard.

I guess the point of this reflection is for us to stop and reconsider the experiences of our patients. Realise how frightening it is to be alone and vulnerable, subject to investigations and treatments you don’t always understand.

We are all in this together,

Collaboration is likely the only solution – that is, patients, staff, relatives, carers, all part of a multidisciplinary team fighting the odds.

*cheyshek = Yiddish for strength/energy/va-va voom

**stramash = Scot’s for ‘mess’