Healthcare staff working in the late 90’s and early 00’s will be familiar with the airplane analogy.
Sometimes a double-decker bus was used.
This supposedly equated either (depending on who was talking and their level of cynicism) to the numbers of patients harmed or killed in US and UK hospitals every day.
The UK planes and buses were proportionately smaller than those in the US, where everything is bigger and better, or in this instance, fatter and worse.
This is my first blog of 2023.
A decade ago, we stopped using these terms to reference harms in healthcare. I am not sure why. I suspect there was because there was an impression that the care provided by the great hospitals in our different nations had somehow become safer.
If you look at any number of graphs produced by healthcare organisations, things did seem to improve – fewer falls, hospital acquired pneumonias and that kind of thing.
As with all measurements, it is what you record and how you record it that is the basis of the data which can be obfuscated.
A decade of Tory austerity followed by three years of Covid in the UK have undone all that.
No one is still singing the Labour Party song of the 1990’s ‘Things can only get better.’
Well.
If I haven’t demoralised you too much already, I would like to return to planes.
I’ve not flown in one in a while although I am constantly assured, they are the safest way to travel.
I think that was a reason doctors and improvers in care latched-on to them ‘we want to be as good as the aviation industry.’
A noble aspiration although flawed in that passengers and patients although both subjects of systems that are built to assure their safety, are dramatically different in that, if a passenger freaks out on a plane, armed guards will tackle them to the ground and silence them. If the same happens in hospital we can’t, don’t and wouldn’t do that.
That is just one example.
There are more.
I’ll let you imagine.
For those who have been watching the TV or reading the news in the UK they will have noticed there is a crisis in our country.
Healthcare (or better, health and social care) is in meltdown.
Years of deconstructing the care sector – taking millions of pounds from councils and stripping people of autonomy, layering-on bureaucracy, crashing the economy and behaving like oligarchs has created a tin-pan mess.
This has recently been reflected in an article in the Emergency Medical Journal. Essentially, for every five hours a patient waits in A&E in the UK, one in 82 people will die unnecessarily in the following 30 days.
One in 82 you think. No bad odds. When you consider the hundreds of thousands of people admitted to hospital in the UK you might think again. And this is for the people who might benefit from admission. If your admission is avoidable or unnecessary – if, for example, your carer didn’t turn up (started new job at Lidl that morning) (Better pay, terms and conditions) and you were stuck in bed and maybe tried to get up and fell and bumped your head but were fine, but stuck, and called an ambulance and are, let’s say, to confuse, 82 years old, and a little discombobulated, you have a risk of being admitted.
In some care homes in the UK there are ‘no lifting’ policies that prevent staff from lifting a person who has fallen; the corollary is, if you are 82, or 92 and fall in a nursing home you might have to remain on the floor for six hours before an ambulance picks you up. By that time, you are so traumatised the paramedics think, ‘Better take you to hospital to get you looked over’ and five hours waiting outside A&E, then 10 hours to be seen by a doctor and 20 hours waiting for a bed. The person is half-gone before the day is done and all because a policy document.
I am on my soapbox.
I’ll step-down.
I’ll get back to planes.
For the past ten years or so, hospitals have adopted a system of alerts borrowed I think from the ambulance service who in turned borrowed from the army – it is called ‘OPEL’ – (Operations Pressure Escalation Levels) with different numbers and colours indicating the level of pressure on their system.
In hospitals, when things become bad (as they are constantly now) they are on OPEL level four, yes, you guessed, colour black.
This means there are more patients coming through the doors of the hospital than going home. There are not enough beds, people are waiting, operations are at risk of being cancelled and the system is under ‘pressure’ (as the managers say).
No one wants to be poorly when the system is operating at level 4.
It means, your heart attack or stroke treatment is likely to be delayed.
This in turn means death of heart and brain cells.
Handicap, disability, or death that would not have occurred if the system was at level 2 or 3 (consuming its own smoke, so to say).
When the black flag is raised, there is a response in most hospitals in the UK.
‘We are at level 4, cancel all unnecessary activities, all hands to the pump (what you do on a ship when it is sinking, I was informed this Christmas)’
And so, what follows is what happens when humans panic.
They run around shouting ‘black’ ‘level 4’ ‘action!’
This, for those of you familiar with the lore of my blog is when the amygdala (almond) fires, creativity ceases, and people shift to survival (fight or flight) mode.
The managers go to A&E and the admission units and stand around, trying to help; the cardiac staff who aren’t doing cardiac things because their cardiac theatres are shut because the operations are cancelled go to the medical unit and offer their support, ‘What can I do?’ They ask an exasperated nurse who is running around, which further stretches the bandwidth of the poor nurse who in turn snaps, ‘help!’ or ‘I don’t know!’ or ‘we are fine.’
The manager or cardiac technician go home later that day, ‘I helped in the emergency department today,’ ‘Very good their children nod with approval.’ (Or, I went to A&E and was told they didn’t need me… fancy!)
The Emergency staff deflate with insomnia, too many sweets, alcohol, or other things.
It’s not very healthy.
And yet, this play is being enacted across the UK constantly.
I can guarantee it.
Do you know an NHS manager? Asked them what happens when things are black in a hospital.
Well.
And this is my point (finally, and where I return to planes).
I have done the same.
‘It’s awful, can you help?’
I cancel my meeting, my paperwork or whatever and try to help.
I often get in the way of people who are doing their job at the limit of their abilities, stretched beyond elasticity and the difference I make is minimal.
The meeting was cancelled, it will be rescheduled for next month and whatever fantastic plans I had to save the world will be postponed.
It is a maladaptive process.
It is the immune response that takes-out the pancreas and creates diabetes. Antibodies doing what antibodies do with negative consequences.
It is not the antibody’s fault, it is the system, there is something awry.
And, equally, I am not suggesting an immunological response to the busyness.
It is a matter of economics.
Last night, after dinner, my daughter was practicing her economics revision for her soon to take place GCSE mocks.
‘What is the economic problem?’ My son asked.
‘It’s the presence of limited resources to meet unlimited wants’ She responded without pause. I am sure she will be the next Jeffrey Sachs or Yanis Varoufakis.
Supply and demand.
When we freak in the hospital, we are supplying more staff to areas that are already fixed, they have a finite number of trolleys, x-ray machines and blood pressure pumps, this (my daughter tells me is called ‘inelastic’) we don’t look at the supply.
The supply, for the most is people arriving at hospital either via ambulance, their GP, their families, or rarely public transport.
Many of these people are older. Many, although potentially ill don’t have an emergency. Or rather the emergency happens after 24 hours in a stretched A&E – the emergency wasn’t the fall, it was the result of the waiting, the dehydration, the pressure sores and so on.
We need to look at the supply.
Our current model, flipping back to the planes, rushes to the scene of the crash and tries to rescue as survivors (?victims) as possible.
We wait, wait, wait, until the crash, perhaps in the Andes or a remote place in the Indian Ocean (to add flavour) and invest time, effort, and resources in patching up those for whom the worst has already happened.
We spend no time at all on checking whether the plane or the passengers are fit for flight. We let them board regardless.
It is easier to prevent a fall before a fall has happened (you look at those who have already fallen (risk-stratify), who are frail, older and very high risk for falling again) and do something about it – provide a rail in their bathroom, stop the culprit medicine. Our current model waits for the fall which happens in a difficult to reach place, waits for them to be rescued then tries to patch them up.
Our system is upside down.
I am not suggesting that we shut the hospitals.
It will be a while before cardiac and orthopaedic surgeons can safely operate in the field, rather, we change the focus, the emergency response.
When the system reaches shit/fan the extra staff should be out with the ambulance crews supporting people at home. Taking the x-ray machine to the person who has fallen, ruling-out a fracture and letting them get on with their day (perhaps also simultaneously doing all you can to prevent a future fall) (Yes, this technology exists – no one is game to work with me on it).
It is me, rather than flouncing around A&E, rushing out to the nursing home with my suture kit. It is me or my colleagues, spending time talking with those at most risk of admission (many of whom don’t want to go to hospital, who know, if they go to hospital, it will only because they are too ill to refuse and will likely die there) and agreeing alternative admission plans.
It is enacting our virtual ward – providing care that is equivalent to the hospital in the home.
This week I met a woman who was very ill.
She was breathing fast; her oxygen levels were low and she’d only managed to drink 100mls of fluid by four pm.
‘I think you might need to go to hospital.’
‘No!’
‘OK, if you promise to drink as much as you can, I will see you tomorrow.’
The next day she was better. She had managed 1400mls. Not as much as an intravenous infusion in hospital but without the risk of snagged cannulas, stopped drips and unnecessary tests and transportation (her last hospital admission had not gone well).
It might sound like I am knocking hospitals – I am not. I will be the first person to ask to be taken to the emergency department for a primary angioplasty when my heart attack happens. It is just, that now, by the time I reach the hospital, my heart will have started to fail, and it might be too late because the system is topsy turvy.
We need to look at the airports not the crash sites.
Stretching the analogy, perhaps even the travel agents.
‘I want to fly to Honolulu.’
‘Do you know the price of insurance?’
The cost of the insurance in the UK doesn’t exist, the cost is the price of the inadvertent harm created by disjointed systems.
GPs, hospitals, community, and ambulance services not working together. Fractured by the limitations of GDPR; as the data companies make a mint, we are dying. Something needs to be done.
Yes, it is toppling the government, general strike, it is a re-evaluation of our fractured system, but first it is using what we have differently, it is responding in an alternative fashion, it is doing differently to what we have already done.
No more crashes in the Andes please.
I’ve had enough of cannibalism.
Dr Rod’s Odd Blog (almondemotion) 