Flow; best left to plumbers.

It perhaps has something to do with my internet settings or preferences, I don’t know; you see, I get a number of emails from different national and international health organisations informing me of conferences and award ceremonies taking place in the realm of Quality Improvement.

This is the science of doing things better in health and social care.

It sounds straightforward and, yes, it is.

Examining what works, measuring, adapting, trialling something different and going round and round again in a virtuous cycle of improvement.

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Add a soupçon of creativity and you might be on to a winner; as they say.

My question about settings relates to the relatively narrow remit of subject matter covered in these communications – flow – how to ensure your patients stream through the hospital system, how to maintain an effective emergency department, discharges before breakfast, improving your delayed discharges, seems to dominate.

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The theme is how we can make acute hospitals more effective; you see, in many instances over the past decade there have been phenomenal improvements in care in hospital – deaths from falls, health care associated infection – MRSA and C. difficile in particular as well as drug errors have all declined dramatically.

When I was a junior doctor, it was expected that patients would develop C. difficile diarrhoea if given enough antibiotics; in some departments this has been eradicated.

Yet, we can’t fix flow.

The reason for this relates to the blog I wrote earlier today – flow, or, the movement of often frail, older people who are experiencing a multitude of complex long-term problems is in the realm of complexity. Sometimes described as Wicked. No one thing works; you need to have Adaptive Solutions – what works for A might make B worse and vice versa. Humans are complex and the systems of care in which we endeavour to provide support are even more so.

Again, I am not really getting at this as an issue, it is more the system bias towards flow that frustrates me.

You see, flow is important, especially in relation to having enough beds available to stop the A&E department overflowing or allowing for elective hernia repairs or hip replacements, but in the overall scheme of things, it is relatively trivial.

And this is my point.

Most of health and for that matter almost all of social care take place outside hospitals.

In the community.

More patients are treated in one day by GPs, community pharmacists, nurses and social workers than are seen in a month in hospitals.

Yet, we tend to focus on hospitals as if everything else is unimportant.

It is Nero fiddling whilst Rome burns.

The real issue is how we support and care for people in the community;

I am not saying that hospitals are unimportant – they are, and I and everyone in society benefits from them, it is just that attention is focused in the wrong place.

Quality Improvement in relation to care in the community; how patients and care home residents are supported would likely provide a far higher return on investment, yet, the light is shone on the hospital; it is in the spotlight, whether driven by media attention or political angst.

We need to find a way of turning this upside down;

I am planning to support a revolution of care in South Yorkshire… Please watch this space; in the meantime, let’s lobby the Don Berwick’s, Albert Wu’s and a host of other secondary care based professors to lift their gaze from the operating theatres to the primary care clinics, care homes and living rooms of older people and the citizenry where most of the work of the NHS and social care happens.

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