Crisis, alert, no beds!

We have a thing in the hospital, it is called a Level-4 Bed Alert.

When this is announced, it advises staff that there are more patients scheduled to come-in to the hospital than there are beds.

(Were the hospital a sink, the drain would be blocked and the water-level rising).

It is a sign that the Emergency Department has too many patients, an indicator the ambulances are stretched as they wait to offload the sick and injured.

With the alert, staff are directed to move-away from so called non-clinical duties and focus on discharge, this is the process of moving patients out of the hospital to make-way for the new.

It is an organisational cry to arms.

Once upon a time these alerts were unusual.

Now they are daily.

I saw something on Twitter yesterday suggesting that the NHS is now at the bottom of healthcare systems in the developed world.

Yes, we are better than Yemen, Syria, Azerbaijan, or Iraq, but they do not really count.

For years I have tried to convince the hospital management to formally communicate this situation to others, principally primary care, or GPs. (It goes-out on Facebook and Twitter although most GPs and sick patients aren’t tweeting during their crisis or in a morning surgery).

You see, it is my contention that although GPs are only responsible for admitting a minority of patients directly to hospital (most arrive via 999), given the bed crises, they are unable, like in the old days to see an old man with pneumonia and send him directly to a bed on the admission ward.

When I was a junior doctor, we hated GPs sending patients directly to us as this meant we would have to organise blood tests (take the bloods ourselves, insert a cannula if required), x-rays and ECGs. In other words, it created more work for the ‘medics’ – those on the wards, but was better for the man with pneumonia as he wouldn’t have spend time on a stretcher in A&E.

Nowadays as there are never available beds the patients are almost always sent to A&E.

This means, for our man – let’s call him Old Adam, the process for getting to that well-made hospital bed would be, Call GP – speak to receptionist – wait for GP to call back – ask for home visit – GP goes out to review* – Old Adam tells GP about their symptoms, their chest is sounded, ‘You might have pneumonia,’ is announced; ambulance is called – ambulance reassess Old Adam, ‘Any allergies?’ Take Adam to A&E, Adam waits in ambulance outside A&E (cold in the winter, too hot in August), he speaks to a triage nurse, then a practitioner (nurse or medical), ‘Any allergies?’ Again. Bloods are taken, ECG, chest x-ray, cannula, intravenous fluids, and antibiotics, call the medical ward, wait for a bed, 15hours later Adam reaches the medical ward (and the medical doctor), ‘Any allergies?’ and so on.

It is a fershleptibobemyse as my dad would say, that is, Yiddish for, a long and convoluted old granny’s tale.

Our system is complex and there are multiple steps and checks and governance assurances along the way.

Recent evidence has demonstrated the longer a patient such as Old Adam spends waiting in the emergency department, the greater the chance of him dying.

None of this kerfuffle is communicated to the GP, ‘I think you need hospital.’

The GPs often worked in hospital 20 years ago or more, long before the Tory NHS demolition derby.

Many are unaware of the pain and sometimes indignity facing the patients (as Old Adam waits on that stretcher, in hospital gown, bottom or testicle peeking-out, he needs the toilet, ‘Just go in your pad,’ he is told.)

It the start of a gradual descent.

Some GPs are aware of this process, not because they have witnessed it recently themselves, but, because their patients tell them.

Old Adam: Please don’t sent me back to hospital, it was awful, the noise, the lights, the food; daily blood tests, urine measurements, pin-prick blood sugars, temperature, and blood pressure.

And yet, we have few alternatives.

I hadn’t intended to talk about the anticipated virtual ward in my area – the NHS has announced plans to open so-called virtual wards across England this winter; these will provide (supposedly) ‘hospital-level care in a patient’s home’** – millions of pounds have been spent developing systems and processes, recruiting additional staff (there aren’t any – remember the Brexit workforce crisis?).

Let’s see what happens.

The virtual ward will only succeed if GPs and paramedics possess the facts.

‘Adam, the hospital is on level four; that means you will have a very long wait if I send you to hospital. We could give you treatment in your home. Which would you prefer?’

Old Adam falls off settee in his enthusiasm for the alternative.

I haven’t carried the narrative of this blog particularly well.

I had intended to describe the lack of joined up working across our health and social care system.

This is where although at a certain level social workers, doctors, nurses and administrators communicate, at another, on the shopfloor, these conversations are often not happening.

We, given our hunter-gatherer brains, exist within a tribal monoculture. Us and Them.

There has been a recent move to recreate the way care is delivered across ‘systems’ that is different towns, cities, and communities, with greater collaboration.

Moving away from a ‘Sheffield’ ‘Doncaster’ or ‘Barnsley’ patient toward the concept of a ‘South Yorkshire’ patient.

South Yorkshire is the major conurbation, in the South of England’s largest county, with the four towns and cities (Rotherham is the other) mostly mixing and merging – one day we might become a megalopolis.

It is not uncommon to hear the doctor, social worker or commissioner announce, ‘Old Adam is a Rotherham patient, that pathway doesn’t apply, it is only for people from Sheffield.’

(Old Adam lives on a street in Rotherham, one end of which is in Sheffield, you get the idea) – maps are artificial, manmade boundaries like race and class that work to divide rather than bring us together.

The new plan, called ‘Integrated Care Systems’ is for us to integrate.

No more Sheffield or Barnsley, rather, South Yorkshire Patient, it is like a line from Imagine, John Lennon’s vision of the Universal.

Maybe when GPs and hospitals and social workers realise that they are not separate, that they are all pushing in the same direction and that the wellbeing of the Rotherhamite or the Doncastrian is equivalent and within the context of a holistic humanity we will get somewhere.

For now, the Level Four is an alarm (not a literal one) that sounds in the hospital and the common good is over the fence.

Flipping this on the head, you could take the R Moog argument that adversity, especially for the ‘man on the street’ is good, as it not only toughens them up, separates the wheat from the chaff and drives innovation, just, as the people rushing to purchase Oodies in place of central heating are contributing to a reduction in global warming.

No, I don’t believe that.

Yes, Mr Moog, your actions will kill lots of old folk this January.

Your polemic will tear us apart, it will drive the divide.

We shall overcome, Old Adam sings to himself as he let’s go of his urine, too afraid or ashamed to ask for help, too tired or weak to shuffle off the stretcher, the noise and hubbub of the corridor (no room in a bay) are too much for him. A notch off his dignity and his life.

*In many areas of the UK, instead of GPs visiting their old and frail patients at home, visiting services are sent, this is nurse and paramedic practitioners (mostly) who, don’t know the patient, don’t have access to the 80 years of their medical and family history, check a blood pressure, heart rate, and say, ‘Adam, you aren’t well, I am sending you in.’

It is another spicule of Tory defenestration of the NHS.

** Can you see the picture of me on this link?