Today we see national headlines on the sharp increase of over 90s being taken into A&E by ambulance, over the last 3 years. http://www.theguardian.com/society/2014/jan/29/use-ambulances-over-90s-hospital It is good that finally we are reaching a point of understanding the huge and growing problems our hospitals face.
Here in Stafford, where we have an unusually large number of elderly people, and we road tested the wrong solutions by cutting social care beds and hospital beds at the same time, we reached this crisis a little earlier than the rest of the country. Now we can see more clearly that the root problems are national. We can see that a number of the people who do end up in A&E would be better not being there, but come because of lack of suitable alternatives.
There is no shortage of theories on the root causes of the increase:
Most people accept that people are living longer because of better drugs, & better surgery. This is a success story, but older patients have the potential to develop a more complex mix of illness, and need a different kind of care, something we have only just began to think through.
The Conservatives say that the problem lies with the changes to the GP contracts leading to less availability of GPs out of hours.
Fingers have been pointed at services like 111 which mean that Nursing homes phoning for help with a sick resident are frequently being advised to call an ambulance.
Labour points to the huge cuts that have occurred to social care, which has meant that many elderly people can no longer access the support they need in their own homes, or in day care centres, and this may mean that they are more at risk of becoming severely ill.
Personally I am pretty bored with simplistic headline points. The reasons for system failure are complex and will vary from place to place. And the solutions need to be built on an understanding of how the different bits of the picture fit together.
The Effects are apparent
The pressure point is always A&E.
The pressures in A&E make recruitment of doctors difficult or are times impossible, leading to the use of agency staff, which can be problematic, and is certainly expensive.
The bed blocking and lack of community beds leads to such problems as breaches in 4 hour waiting times, A&E closures and Ambulance waits
Lack of beds causes inappropriate use of Intensive care beds, contributing to a national shortage of intensive care beds.
Pressure lead to cancellations in elective surgery, causing distress or worse to sick patients.
All of this shows up in the indicators that the hospitals routinely measure and in the statistics that are used to make the political weather.
There is political pressure to seek untried radical solutions.
The high political profile of problems with the running of A&Es leads to a natural quest for magical solutions, and therefore to the use of management consultants. Many of which are to be found in this article on the way the NHS is now being managed http://t.co/zsf9FiYsLX
Politically the two biggest worries are the escalating costs of A&E and acute care, and public perception. (This interview with Jeremy Hunt http://m.hsj.co.uk/5067494.article indicates how much importance he lays on the public perception of quality)
The expert advice on how to square this circle and give better quality for less outlay, is to reduce the demand by centralising service to centres of excellence with the hope that this will discourage “unnecessary” attendances and admissions.
The theory is that Hospitals will refocus on providing acute medical care, The hope is that patients will perceive this as a better service because they are being offered better preventative services (to be developed) and better follow on services in the community (to be developed).
There is talk of rapid response services to help keep people at home, and different forms of telecare and digital interventions to help monitor people’s conditions without them needing to travel to surgeries or hospitals. (These novel solutions are to be developed)
Who is in Charge around here?
The NHS is still reeling from the latest reorganisation, and the different organisations are still finding their own feet.
The roles of the CCG, the Partnership Trust, the Hospital Trust boards, the patient participation panels. the Health and Wellbeing board, The Borough Health scrutiny board, The County council Health scrutiny board, or the Joint accountability board, let alone the CQC, Monitor and NHS England are all pretty unclear, certainly to the public, and maybe to some of the participants.
Communication between organisations may be less than perfect, and may be made problematic by the fierce competition for scarce resources, and for the need to shake off blame when the cracks in this imperfect service show up. The scale of the challenge and the potential problems are covered in this article http://www.theguardian.com/healthcare-network/2014/jan/28/integrated-care-needs-people?CMP=new_1194&et_cid=53286&et_rid=8769516&Linkid=http%3a%2f%2fwww.theguardian.com%2fhealthcare-network%2f2014%2fjan%2f28%2fintegrated-care-needs-people%3fCMP%3d%%_p_cmp%%
The channels for raising complaints when there are gaps between services are unclear, which will probably result in increased caseloads for MPs and Councillors, with cases that they cannot hope to resolve.
Are we asking the right people?
The most influential people in determining the future shape of our Health services are organisations such as Monitor, which are packed with accountants and management consultants http://t.co/zsf9FiYsLX
Monitor have created the Clinical advisory Groups, or CAGS, which are selected groups of clinicians. These advisors, starting with the assumption of the budgetary cuts, in meetings run and recorded by management consultants appointed by Monitor, set out the “direction of travel” that is the road map used to determine the future of individual hospitals.
The models that the CAGs provide to the TSAs and to CCGs considering the future of services in their areas do not always fit well with the experiences of the people delivering care on the front line. In Stafford we were surprised when the process did not involve contact with the front line, resulting in some very inaccurate assumptions being built into the process.
Channels of Communication between TSAs and the front line, or CCGs and the front line seem poorly travelled.
There is plenty of talk of using new technologies to improve care and bring it closer to people. Is there enough communication between the people who understand care needs and the people who understand the technologies to make this happen?
In a few weeks we will know, at least in outline, who is to be given the responsibility for our hospital services in Stafford. The likely outcome is that some acute care will shift to Stoke, with the promise that the majority of care will be delivered in Stafford, or potentially even closer to people’s homes.
I would love to say that this has been such a thorough process that we will be getting the best possible solution for our community. I am unable to say that. The process has been deeply frustrating,, and few people in the community believe that it has produced the right results , but the process rolls on regardless, and the announcement by the Secretary of State will mark a new chapter in our health service.
The population of Stafford are now far more aware of issues within the health service than the majority of the country. We are pretty wary after the last six years of “process” inflicted on the community and we will be watching carefully.
The promises that individuals in the community will not suffer as a result of the changes will need to be kept at the front of our minds, and they will need to be met.
How the rest of the country will view events at Stafford remains to be seen. There has been a tendency to accept the apocalyptic vision of Mid staffs presented by the papers, something that does not fit the experience of the Stafford people, and over the last few years many people in the Health community have been happy to accept Stafford as a one off, and therefore nothing to do with them. Better informed people know that this is not the case, and if the reconfiguration of Stafford goes ahead as expected then I expect many other hospitals to follow us down the path laid out by the CAGs
The Government is keen to make Stafford disappear as an issue. Because of that they have been prepared to pump a considerable amount of money into the area in order to help the CCGs commission a service with a strong community base that will work for us, whilst at the same time complying with the “direction of travel” set by the CAGs. If this goes forward then I think it is in the interests of all if people with specialist knowledge of community based services share their knowledge with us.
This is an opportunity. We can if we set our minds to it begin to create a health service for this area that will meet the future needs of our population. We have the potential to be a blue print for the future of District General Hospitals and also for Community based health care. Achieving that is going to take determination to communicate well.
We have been through a difficult few years, in which communication within the community has not always been easy. Last year 50,000 people marched in Stafford, showing an astonishing commitment to the idea of the NHS. In the year that has followed the staff of the hospital and the people who use the services have had a chance to find their voice. The energy present in the public meetings over the last year has often been on the explosive side but if it is harnessed well, it can achieve a lot.
I do not know what Jeremy Hunt will decide in the next few weeks but I do know that collectively this community has the power to build something good. I hope he will give the right signals to make that possible.