Monday, 12 August 2013

At some point we have to understand care pathways.

In Stafford we are currently facing the reconfiguration of the Health Service, through the agency of the TSA. This could set precedents for hospitals all over the country.  The verdict of the people on the receiving end of this process so far is “It is probably best not to do it this way”.

The Central question that the Trust Special administrator (TSA) has to try to answer, on the behalf of its boss Monitor, and Monitor’s boss the Secretary of State for Health is “How do we make health care financially sustainable whilst improving the quality of service?”

The most likely answer to this question is “By doing things differently”.

The challenge to the Health Service is so great that it needs a radical approach, which probably has to be centred around prevention, and integration, and also needs to take into account the issues of specialisation and the right place to perform the right tasks.

The role of the TSA in all of this is an uncomfortable one.

The TSA are here because the question is being phrased in terms of an individual hospital, which is “financially unsustainable”.  Because the question is about the future of an organisation it is probably not surprising that the proposals the TSA have made are structural. They are about what bits of the service should be performed where, and about who should commission what from where.  In the TSA's defence I am not sure what other options they had, given their remit?

The TSA do see the problem. They have had to focus on finding organisations that would offer to provide the service we need, and they see that this is not the end of the story. They know that integration plays a key role in making the future of the service work, and they know that they have not addressed it in their proposals. They are open to suggestions, and we need to help them with this.

The job of the TSA was to sort out the financial problems of one individual organisation that is part of a complex network of organisations and services. Delivering a health service and improving the quality of care depends on making “care pathways” work, and these pathways cross many boundaries.  The TSA cannot even begin to deal with this.

The TSA took a lot of stick at the first of the public consultation meetings because it emerges that they had not been to visit any of the departments whose services are now under threat. To those of us that see the importance of these services, the teams that deliver them, and the way in which they connect with the community around them this seems a very odd approach. Why would you not want to start by knowing what is there already?  To the TSA it clearly did not look like that. They needed to construct a viable structural solution from the ground up, and the existence of strong teams within the organisation were simply not relevant.

If you want to “Do things differently” then maybe beginning with what is there, the teams, how they relate to the wider health service, the way in which clinical pathways for a whole range of different conditions operate, the barriers which prevent people moving from one part of the pathway to the next, could have offered a better starting point.

We do not know what the outcome of the consultation will be, we do not know if we can make the case for the services that the TSA threatens. We are pretty certain that we can make a very strong case for ensuring that no other trust will go through a process quite like this again.

Whatever happens, when the TSA leave town we will be left with the task of trying to make a health service work for us, and if we haven’t got to grips with understanding integrated care pathways by then then this is where we will need to begin.  

Fragmentation and Kindness?

You might say that Stafford is currently faced with “re-configuration” of its Hospital service is because a number of people experienced care which they felt was unkind. As I look at the recommendations from the Trust Special administrators about the future of the service  a key question I am asking myself is "will this improve the chances of people being treated kindly"?

As an aid to asking these questions I am currently reading “Intelligent Kindness” which was written by John Ballatt and Penelope Campling as a reaction to many of the issues raised by the first Francis report.

There are so many powerful points in this book. This is selected almost at random. (P88 In the chapter Co-operation and fragmentation. Pulled in all directions. )

The writer’s parent was being assessed for a knee operation. She asking how long her hospital stay would be. The answer she got was that it all depends on which CCG you come under. If it is “city” then she would be discharged when clinically ready, if it was “community” then it would be after 2 days. This is because “community” CCG had commissioned community based care for people being discharged home.

The writer then goes on to think about how confusing this must be for the staff of the ward dealing with patients in the next bed to each other, and the same conditions, but being given aftercare in completely different ways, and how this confusion would communicate itself to the patients and their relatives.
The underlying point I would make is that a patients experience of treatment is made up of their whole "pathway". Diagnosis, preparation, treatment, aftercare, discharge. These all need to work together, and there are many barriers that make this difficult.

If more acute care is being directed to super hospitals (determined by “financial and clinical sustainability”) then each  hospital will serve patients from a large number of different Clinical commissioning groups, each with their own service level agreements. If this is so then you are adding a whole new layer of complexity to the work that the staff must do. Staff will in the above example also be aware that failure to discharge patients on time if they are “community” patients will incur financial penalties. This creates additional pressures for them. Will any of this add to kindness?

Commissioners will aim to reduce the length of hospital stays, so we can expect that periods is an acute ward will be as short as possible, this might then be supplemented by a stay in a step down ward, (I am not sure that we understand enough about this, what are the rules about how step down beds will be used? How will they be paid for? Are they time limited?) Will that add to kindness?

The aim will be to discharge to the community as quickly as possible, but how good are the services to support people when they are discharged? Will that add to kindness?

How well does the centralisation of acute care, coupled with the fragmentation of commissioning and of local service provision actually work together in practice?

What patients want is to be supported at each stage of their “pathway” by teams that co-operate effectively.  Will the new model of hospital care that we are moving towards make this more or less likely?

Friday, 2 August 2013

Watch out for the baby in the bath water!

After a first full day of reading my way into the TSA recommendations for Mid Staffs my thoughts are getting clearer. The report is very largely about money.

This is a small trust. Small trusts struggle financially. It is pointed out to us that it would be unfair to expect the other neighbouring trusts, many of whom are also struggling, to bail us out, in the way that we did for them in 2006. The extraordinary pressures on Mid Staffs over the last five years have added greatly to the costs of running the service here. The task that the TSA had to do was to find a way to make the service in the key word of the report “sustainable”.

It seems that the way in which the TSA have approached this task is essentially to start with a blank piece of paper. What are the services that must be offered, who is willing to provide them, how would that impact on other neighbouring hospitals. Their recommendations are built on this.

Let me first say I welcome the proposals to link Stafford and Stoke, because I believe that this does deal with the “small hospital” issue, and will mean that it is easier and cheaper to attract the staff that we need, and that by allowing staff to work at both hospitals it ensures that skills are maintained. This addresses the issue of making the service “clinically sustainable”.

I also welcome the proposals to bring more elective procedures back to Stafford, which gives a better financial basis for the hospital to go forward. It is the loss of the elective processes, on top of all the other pressures over the last few years that made Stafford “financially unsustainable”.

As Jeremy Lefroy has been pointing out regularly in parliament, the Tariff system for Acute and emergency medicine, which was put in place in 2009 with the idea of focusing more spending on prevention, means that acute medicine is being run at a loss, which largely explains the national crisis in A&Es. This needs to be addressed nationally as a matter of urgency.

I also cautiously welcome the development of assessment units for the Frail Elderly and for Paediatrics, though the way in which this is done will be important.   

What shocked me was the realisation that the TSA when they threw out bath water do not seem to have seen the baby.

We are asked to be thankful that A&E is to “remain as it is” and yes indeed it is a good thing that there will be a consultant led A&E if only for 14 hours a day. This is a decision that the TSA will have seen was inevitable, in part because of the strength of public feeling, but also because when they look at the emergency medicine networks in the region and read the incredibly strong representation from the neighbouring A&E leads that it is very clear that you cannot run this system without an A&E at Stafford.

The “remain as it is” leads us to the question – But Is it? The answer is “No”. Our A&E is currently supported by a level 3 Intensive care unit, which is able to deal with a given level of critically ill patients. If they downgrade this to Level 2, which is proposed, then this will mean that ambulances that currently stop at Stafford will for a number of patients carry on to Stoke. The effect of this experiment would only be discovered over time. We have been hearing for some time that there would be a new creation a level 2.5. It appears that this means that the ICU would deal with level 2 patients in house but with anything more serious they would “stabilise” and ambulance them off to where ever a level 3 intensive care bed could be found.

The ICU network that supports our health system is over stretched. There are not enough ICU beds. When there is a critically ill patient there can be frantic phone calls to find a bed, which can be at a considerable distance. There was the recent tragedy of a lady who finally ended up dying in Hereford some months back.  The distances are a problem, not only for the patients, but for the efficient management of staffing. When I asked the question the staff patiently explained to me that transferring a patient to another ICU ties up a doctor and a nurse to travel with them and to then travel back. In the hours this takes their skills are lost to the hospital.

The advice the hospital working group has been given by the Royal college of physicians is that having a level 3 ICU is central to the hospital being able to offer the services that we as the public wish from it.  With ICU level 3 then the hospital can deal with the majority of cases excluding Stroke and Trauma which already go elsewhere. Without it then the level of treatments will be limited, and Maternity and Paediatrics and any acute surgery become impossible.

A key part of the argument for the next few months will be about the level of critical care. How much would it take to give us back a Level 3 ICU? Is there a major cost implication in going from a level 2.5 to a level 3? Should as Jeremy Lefroy suggests the cost of a level 3 be met nationally as part of a national network of scarce Critical care beds?

Which brings us to the baby.

What did shock me last week is a visit to Maternity and Paediatrics, which showed me that some of the assumptions I had made about the way the TSA would carry out their work were wrong. I had assumed that the starting point for their task would have been to visit the different departments in the hospital and to develop an understanding of what people were doing and why, and find out what we already have here that is valuable.

It was clear to me as I listened to the people from Maternity and the Paediatric departments the immense pride that they have in their work, and the way in which the Paediatric service in particular has developed over the years to meet the particular needs of this community. The service may be unique, It is certainly valuable. The TSA do not currently know this, because they have had no discussion with these departments.

The future of medicine needs to be in the development of integrated care, linking primary, secondary and community care, and working with the wider community to prevent illness and support ill people. District general hospitals are perhaps the best placed organisations to be able to deliver this. The Paediatric service we have in Stafford does just this, and the TSA that are downgrading the service do not know, because they have not looked.

The TSA have come to this task armed with reports from the Royal colleges to support their decisions to centralise care in bigger hospitals. I know that there are many strong arguments against this. Are there enough people speaking out to make the case for the District General Hospitals of the future?

For me Stafford is not just about Stafford, it is about the future of the NHS and the future of the District General Hospital. We need the help of others who care about this to come to our aid now.

I do not know what the next few months will bring, but I hope that this period of consultation can bring us all a better understanding of the kind of service we need for the future, and the way we can build on valuable local knowledge to give us that.

If we go back to the Academy of royal medical colleges report they are very clear that reconfiguration of the health service can only be done successfully with the support of the community, and that the pressure that TSAs have to work under are not an ideal starting point to achieve that. I hope that that TSA will go into the consultation process prepared to listen, prepared to understand more, and prepared to help this community achieve the outcomes that it deserves.