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Back in the trenches

In his latest instalment, our diarist rolls his sleeves up to spend a morning on a busy acute ward – and learns about the holes in care

The story so far…

Dr Peter Weaving is gamekeper turned poacher – he’s left his CCG to work for the local trust, though his GP day job continues. Until last month he was vice chair of Cumbria CCG but now begins 2013 as GP clinical director for North Cumbria University Hospitals Trust. After six years of being on the other side of the table he’s prepared for new colleagues to say ‘you spent years telling us to do more with less – now let’s see you do it.. ‘

I’ve struggled, perhaps through shell-shock, to get started on this diary. In fact I was kickstarted into it by someone else’s, far more erudite, publication.

He, Mark Newbold, is another clinician-turned-manager albeit on a quantum scale grander. He’s a consultant-turned-chief executive of a big foundation trust. But it was reading about his fight with winter pressures and the four-hour A&E target that finally made me put pen to paper.

He makes a number of valid points about how his organisation regards it as a failure if fewer than 95% of patients are processed through and out of the A&E department within four hours. Notwithstanding the numbers, complexity or outcomes for said patients, he reasonably observes that this is a rather mechanical measure and subject to some powerful forces completely outside his and his clinicians’ control. The only reassurance I could offer, by way of solidarity, is that it is also seen as a failure for the commissioner, the responsible CCG.

On my second morning working in my acute trust I rolled up my sleeves, removed my watch, washed my hands and joined the 8am post-take ward round; my first for 30 years. I tweeted my anxiety beforehand about being asked any hard questions but the only response I got was the ancient quip about ‘What’s the bleeding time?’ When we finished it was about bleeding midday.

I will write another time about the detail of the patients and their conditions and their need – or otherwise – to be in an acute medical bed. Suffice to say I learned more about the holes in primary, community and out-of-hours care than I did about hospital medicine and its systems.

What I do wish to describe is the overwhelming sense of chaos one perceives on a busy acute ward with patients varying from the clearly young, fit and well, although horizontal, to the clearly moribund and appropriately palliative – and every wavelength of the spectrum in between.

The only person who seemed to know what was going on was the bug-eyed registrar who had been up all night and wanted to get some sleep because he was back again that evening for more of the same. The consultant was a locum, the staff nurse was on her first shift back after days off. An F1, like me, was enthusiastic and clueless. Or was that the medical student?

In short this team, which represents a fair amount of human resource, seemed ill-equipped to make rapid decisions about onward disposal, discharge or further management of the typical long-term condition, multiple co-morbidity and polypharmacy punter we spend decades getting to know in our consulting rooms when they are not additionally acutely decompensated in some way.

I will leave you with two questions. How do they do it? And: Is there a better way?

Readers' comments (1)

  • I was invited to join the same post take ward round at an acute medical unit and observed some of what Dr Weaving describes. My observations as a non-clinician were that there had to be another way, as people couldn't keep moving faster and faster. It seemed to me that people had to find a way to gain time by working smarter. Two main issues were:

    1/ The junior doctors seemed primarily focused on data gathering with very little clinical thinking going on around the purpose of it. Clinicians lives were being made unnecessarily harder by the excessive (and expensive) data that was gathered as the more there is the harder it is to make sense of it. It struck me that the formal use of a written down differential diagnosis for each patient could act as a good anchor for everyone. It would give a sharper focus and purpose to the discussions such as why is the test being ordered rather than let’s order a full blood count and see what comes back. Tellingly, one of the consultants on the unit shortly afterwards brought in an edict that the juniors would have to present their cases and always have 3 possible diagnoses. Initially this was viewed with horror but pretty soon everybody valued it!

    2/An inordinate amount of time was spent on handovers with endless clinical data being repeated ad nauseam . There must be a more efficient way to do this. Again, I thought that the greater use of a differential would help people focus their thoughts around the issues that really mattered rather than passing on a ‘data dump’ to their colleagues.

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