Monday, December 17, 2007

The grim reality of targets

This tale from a friend tells the story of the government's targets and how their reality is rather different to the propaganda which they are used to create. Dr X is a specialist registrar, only a few years off being a consultant, and Dr X was working an on call shift at Hospital X somewhere in Joseph Stalin Brown's NHS.

Dr X was rushed off his/feet and had four very sick patients to deal with. One of these patients was is status epilepticus, while the others were all not far away from needing a trip to the intensive care unit; hence Dr X felt he/she needed to stabilise these patients before doing anything else. Dr X was pretty tired, dehydrated and in need of a break, but he/she soldiered on anyway.

Dr X then got a call from a manager who informed him/her that there were some patients in AE that were about to 'breach', ie go beyond the 4hr AE waiting target. Dr X politely told the manager that he/she had to sort through the patients based on clinical need, not political need; and that the patients waiting in AE were not nearly as unwell as those which he/she was currently in the process of sorting.

Dr X then continued about her business but was rung again by the busybody manager. The manager informed him/her that should they not see the patients before they 'breached', there may be a question of disciplining him/her. Again Dr X told the manager that it would not be appropriate to risk the lives of critically ill patients to prevent these patients 'breaching'.

Dr X stuck to her guns and sorted out the sick patients, and in fact Dr X stayed in several hours late to ensure that all the patients were sorted out appropriately. The kind manager had promised to find Dr X somewhere to sleep in the hospital as it was too late for Dr X to get home. Unfortunately the manager rang Dr X to say that this was not possible in the end and that Dr X would have to sort something out. In the end Dr X slept on a friend's floor on some hospital linen as work began bright and early the next day at 6am.

This tale is no exception, it is now a matter of routine for managers to abuse highly skilled doctors in this way. This is how a Soviet style system works, the most incompetent and stupid people rise to the top so that they can order around the most able. If something goes wrong it's always the fault of the able person on the ground, it could never be blamed on managers who bully and victimise staff to satisfy our dictators in government. This is NuLabour down to a tee, this is Gordon's idea of progress.


Surreptitious Evil said...

'Tis just remarkable that there was a manager anywhere near the hospital when it was "too late for Dr X to get home." When did NHS administrators start keeping clinicians' hours?

Or is this a direct result of needing some pathetic bully on hand to enforce the targets?

the a&e charge nurse said...

Dr De'ath, as you know, the 4hr A&E target predated the goblin kings ascendancy to the throne by 4yrs.

In 2003, our Trust was amongst the first wave of hospitals to intoduce it, except we were expected to achieve 90% back then, rather than 98% today.

It is important to remember that patients used to die in A&E waiting for a doctor.
See the case of Thomas Rogers who slowly bled out from an annyeurism because a doctor was unable to see him for 9hrs - and when he had finally worked his way to the top of the queue [or collapsed] it was too late to resuscitate him.

Of course, some patients, like Elizabeth Jones, didn't even make it to A&E [because the department was too rammed] and so quietly died in the back of an ambulance which was presumably waiting to be triaged.

Remember the frequent media reports [pre-4hr target] about patients being "warehoused" in A&E, including one case of a 90yr old woman being stuck on a trolley for 4 days.

The longest wait in our department, incidentally was 3 days, for a patient with MRSA waiting for a side room.

As you know there has been a huge recent upturn in A&E attendences, Wanless put the number at 19million last year [and rising, perhaps in part, because we no longer have effective out-of-hours GP services].

I think your analysis is far too simplistic [noble doc/evil manager], although I agree that some managers don't give a shit about clinical standards, nor recognise the implications of duty of care that all docs & nurses owe to their patients [which is disappointing given that a fair proportion of them are ex-clinical staff].

But lets assume the 4hr target is jettisoned, given the insatiable demand for emergency care, and the recent history of shambolic A&E departments overwhelmed by demand, what is the alternative ?

Or put another way, despite the fact that docs and nurses used to moan ad nauseum about patients being stuck in A&E for hours [or days] on end - nothing was ever implemented to significantly improve services, so to my mind there was a tacit acceptance [amongst clinicians] that very long waits were not nearly so bad as some patients would have you believe ?

Roger Thornhill said...


The Goblin King's hand is all over domestic policy and has been so since day 1.

This issue is all about central targets from a monolith.

We need to dismantle the monopoly and not prevent a plurality.

Pascal said...

A&E, so if I understand correctly what you are saying, you need to be told to see people within 4hrs otherwise people die.

And there was me thinking that it was a matter of doing one's job properly, being organised, and, most importantly in my book but what do I know, actually giving a shit.

Funnily enough, my few experiences with the NHS did not convince me that those 3 conditions are very much in abondance.

the a&e charge nurse said...

Thanks Roger - yes, Brown cannot disassociate himself from this policy, but........

In the old days [after a particularly shitty shift] there was usually lots of chin rubbing, and harrumphing from hospital staff, and comments from patients claiming that A&E was like a "third world country", and probably with some justification if certain deaths might have been avoided.

The problem [until the target was introduced] was that staff would be confronted with exactly the same chaotic conditions the next day and the next, in other words the problem was chronic and unremitting, no matter how much staff [or patients] droned on about how unfair it was.

In seemed [in general] that individual A&E departments were powerless to substantially influence their lot which sometimes resulted in patients bleeding to death on a trolley, or dying in the back of an ambulance - what a disgraceful state of affairs, eh ?

Admittedly, since the introduction of the target we have substituted one set of problems for another [as exemplified by Dr De'aths vignette] but OVERALL things are probably slightly better for patients [in A&E] than they were say, 5yrs ago.

Personally I'm less concerned about political dogma providing the majority of patients receive a safe and equittable service.

Pascal - please remove your head from your arse, it tends to impede any perspective you might have on this rather thorny conundrum.

FlipC said...

If you judge any service by targets you will find the service will work to them to the detriment of everything else; shame that the people who set them often have no idea how the service works.

For some reason it reminds me of this from the Magistrate's Blog, particularly item 9.

Garth Marenghi said...

now people die while the well patients are seen instead of them as they might 'breach'

improving the service is all about improving capacity and investment, and keeping decisions based on CLINICAL need, not political need

ae CN, you make a point, things have got better but's it's down to increasing capacity,

it's the same as other targets, if the target comes with no increase in capacity then it makes no difference, the targets are not the driving force for any improvement, it's a big red herring

the A&E Charge Nurse said...

Good points as always Ferret, although I can't help thinking that references to the "4hr A&E target" is a slight misnomer.

As you know hospital throughput depends on a great deal more than what happens during the first few hours in A&E.

Multiple factors have been highlighted time and again which are known to impede best use of resources - poor discharge planning [waiting hours for TTAs/transport, etc], prolonged waits for a radiology report [see Otto Chan], inadequate availability of porters/cleaners, pathology equipment that keeps breaking down [blood gas analysers, trop T measuring devices], etc, etc.

Now it may be that there is simply no capacity left in the hospital system, but allowing chaos to prevail at the "front end" is fraught with dangers, and this is exactly what used to happen when there was no minimum standard when it came to waiting times.

It may be that one compromise would be to increase the time limit to 6hrs, say, or better still reduce the percentage from 98% to 90% - as one of our [decent] bed managers is fond of saying, at 3hrs 59mins we are heros, but 2 mins later we are shit.

I absolutely agree that clinical need should be the gold standard - but all too often, clinicians are in direct competition for finite resources [the robbing Peter to pay Paul syndrome] - complex issues arise because of this although it is completely unacceptable that a dedicated Reg should be bullied or harrassed for simply doing her job, I'm totally with Dr De'ath on that one.

Anyway, I going to shut up now because I fear the marketeers might hijack our discussion to promote their own argument to usher in the fat cats, and perhaps we can at least agree [despite our various differences] that private A&Es are not the best solution ?

Devil's Kitchen said...

A&E C/N,

One of the problems might be, IIRC, that we now have significantly fewer beds in the country than we did ten years ago. I'll go and check the figures somewhere, but it's of the order of tens of thousands of beds, I believe.

Part of this, of course, is because of appalling PFI contracts which, as you know, I am not a fan off.

However, this must cause more congestion in the system so, whilst A&E capacity has increased (and got better to an extent), there is now a logjam in the system when people need to be admitted.

This is down to bad planning -- and people trying to plan such a huge system is what causes the problems in the first place.


P.S. For what it's worth, my experience last year of A&E did seem to be a little swifter to get seen initially.

However, my g/f was seen by four separate doctors who went through precisely the same questions and seemed not to have consulted with any of the previous doctors, before any treatment was suggested.

This cannot be a good use of resources.

the a&e charge nurse said...

Devil - your point about x4 doctors is a good one, and one I've heard before.

To avoid meltdown A&E doctors have to be sufficiently experienced to be able to manage the patient quickly and effectively [in my experience this usually requires SpR or consultant expertise as a rule of thumb].

But in all likelihood your g/f was probably seen initially by an A&E SHO, or FY2 as they call them nowadays, and then a more senior A&E doc [which is par for the course].

In essence hopsitals must balance the learning needs of junior docs [first 2yrs post med school]with quality of service, and it's not always easy I'm afraid.

As you say once you are referred to a specialty [as must have been the case if so many medics gave an opinion] then although doctors 3 & 4 will have read their colleagues notes, they act as though starting afresh [in order not to miss some important detail that may have been overlooked during the initial consultation].