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Hospitals desperately need an overhaul to improve access

Dr Des Spence

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Over the past few years I have been involved in helping to reorganise practices in difficulty. Practices struggle because they hit a tipping point and enter perpetual crisis management. Crisis undermines recruitment and retention, strains relationships and leaves organisations paralysed.

The art is to stabilise the practice and allow space to instigate change. In my experience, through this process of restructuring services to deliver better access and therefore care, it is possible to achieve large efficiency savings.

During this time what has struck me is the sheer volume of the work in general practice and relative lack of resource we have. A practice might be caring for 10,000 patients with a budget of around £1 million per year, a large sum of money but not for offering high quality, unlimited access.

The local hospital caring for the same 10,000 patients receives around £9 million a year. Hospitals have roughly 10% the level of patient contact compared with general practice, so it is receiving roughly 100 times more resource per patient seen.

Why can’t consultants offer 15-minute appointments and see 30 patients a day? How many face-to-face clinical sessions are consultants actually doing? 

Despite these resources the hospital access remains woeful. Waiting times of months upon months. Appointments cancelled at short notice, consultants never phoning back, referrals bounced, work dumped – ‘suggest patient needs anticoagulants’ meaning guess-who taking on years of testing and follow up – and specialists promoting inappropriate polypharmacy, with many obviously in the thrall of Big Pharma.

Why do we have to wait months for patients to be seen? Many specialties are outpatient based, such as dermatology, ENT, rheumatology and the rest. Why can’t consultants offer 15-minute appointments and see 30 patients a day? How many face-to-face clinical sessions are consultants actually doing? Why hasn’t expanding consultants numbers improved access? The A&E is front door of care, so why is it so dysfunctional? There are lots of senior doctors in the hospital, so why are they not deployed in A&E during busy times? Why is it that junior staff are still seeing the sickest patients?

Consider that 5% of consultants earn more than £175,000 from the NHS and 50% have undisclosed private income. The last consultant contract is a spectacular failure of productivity and waste of money.[1] Worried patients feel pressured to side step the queues by going privately (to see the same NHS consultants). So as ever, the poorest get the poorest service. Even in supposedly egalitarian Scotland we are only paying lip service to social equality.

The hospital sector is in perpetual crisis and the system seems incapable of instigating meaningful change. More of the same isn’t working. The BMA is a not professional body but a trade union acting to protect income and status of its members, leaving hospital care riven with restrictive practices and crippled by 19th century hierarchy.

Hospital care is crying out for root and branch restructuring. This involves adopting new technologies and fundamental changes to working practices of the clinical staff. Many, many consultants are deeply frustrated, know all this and want meaningful change.

Productivity savings, you bet.

Dr Des Spence is a GP in Maryhill, Glasgow

1. Bloor, K et al. Trends in consultant clinical activity and the effect of the 2003 contract change: retrospective analysis of secondary data. J R Soc Med 2012; 105: 472–479

 

 

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Readers' comments (12)

  • Blah blah, blah blah blah.

    If only a small % of trusts are failing you can argue for better management. If they are all failing the issue is the system that can’t raise enough money to treat patients.

    A cheap NHS is not the same as an efficient NHS.

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  • Consider if a 10% increase in income in a department allows for slight over staffing rather than permanent under staffing. It would allow time for professional development, in house teaching and quality improvement in the summer without burning out the staff on an always empty rota so that by winter the full team can step up to managing busy periods.

    In reality the hospital is told that it needs to provide a service for £X, so that they can't employ full time staff, instead waiting until the winter when emergency funding is released for locum staff - some of whom might be more disposed to work as an employee if the hospital wasn't perpetually in crisis and shortage no matter what time of year it is.

    10% increase from central government will never happen. It can only happen if patients can top up their care, ensuring the patient, not HMG, are the customers.

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  • Service provision expands or retracts to fit the budget. However secondary care is normally bailed out when in debt. Hospitals are only now having to deal with financial cut backs, but secondary care has more political power and is still frequently bailed out. The same can not be said for primary care, which is allowed to whither on the vine, despite the expectation that the Govt wants primary care to take on more secondary care.

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  • A separate gp union would be a start, with an associated royal college that set its own gp guidelines and standards.

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  • I work a few sessions in out of hours and also A&E as well as doing GP locums.
    Hospitals are incredibly inefficient, with duplicated paper and computer records, huge amounts of time spent repeatedly logging into several different IT systems and recording rubbish such as ‘ no safeguarding issues’ and lots of staff sitting about having a chat or checking their phones. Hospital ‘managers’ and all consultants should be forced to spend time working in GP land. MAybe they would wake u and smell the coffee !

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  • Well written Des;

    Unfortunately the other articles, on a similar theme, over the last 40 years have been equally well written.

    Most consultant activity consists of a letter a GP ,yet they are never taught how to write a letter,the concept of concise accuracy is alien to them

    The NHS is not designed or indeed intended to work,it is simply the physical manifestation of a political promise. You would no more expect it to work than say the M6, or the cabinet reshuffle.

    That said,some departments offer truly amazing outstanding service,but nobody is going to ask a GP who they are.

    Of course in fundholding days all departments offered truly amazing outstanding service,a service that truly worked. Unfortunately a service that works is offensive to the college and the BMA and they campaigned against it.

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  • Vinci Ho

    Not sure an anti-secondary care, anti-consultant sentimentality is helpful here. I always believe we are all under the same flag fighting against our common enemy , the leader of which had just earned more letters in his title(i.e. he will make even more enemies).
    The old Chinese saying ‘the teeth are exposed cold when the lips die away’ well applies here , instead.
    You can say stop going on about the politics and we can reform and reform. Reality is the politics will become even more treacherous and rediculous ,stifling any permanent,rational remedy.This is not a war just for ourselves but for people of the county.
    We become the dumping ground of workload from secondary care because resources (remember my full definition of resources) were ruthlessly stripped everywhere in NHS . There is always a fear of making mistakes consequently while CQC and GMC are breathing behind our necks. Morales are low in general practice but also in everywhere else. Capable colleagues left as part of the whole phenomenon of a government failing to deliver.
    ‘’ When the hierarchy lost the WAY , people had already left their faith and morale behind for a long while. Under such circumstances, sympathy is more meaningful than schadenfradue when somebody was found to make a mistake or commit a so called ‘crime’ ‘’. (上失其道,民散久矣。如得其情,則哀矜而勿喜。)

    Analects

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  • Consultant need to work for the private sector or the nhs. Choose one or the other. Too many perverse incentives are at work to allow meaningful change.

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  • I agree with Des Spence about productive of consultants. I have recently finished training and in 1 of my rotations it was GP half of the week and the other half was doing neurology OP in a hospital in North East (I won't actually name it!). My CS in the hospital and I decided to go to the different consultant secretaries to see which OP clinic I can attend on a regular basis. One of the full time 10 PA neurologists when we actually looked at his timetable was rather quite shocking to us both. Of the 10 PAs, he has 2 MDTs (1 within the hospital and 1 in the regional tertiary centre), 4 PAs for "admin" and 4 PAs for OP/ward patients. I wish in general practice I can have 4 paid sessions for just admin work!!! My CS is not a neurologist but works in rehab and he said his MDTs are always at lunchtime dashing between clinics and wards or on calls he cannot imagine having a PA in its own right. And you wonder why it takes about 4 months for an urgent neurology appointment.

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  • I can't believe you are being so negative about our hospital colleagues. Do you not remember when this consultant contract came in and consultants were suddenly going to be paid for the work they did, because the government thought they were all on the golf course half the week. Productivity went down because the trusts couldn't afford to pay for all the unpaid work they had been doing up till then to keep things going, and they got p'd off with being told they were lazy all the time. In some cases they were told they were not allowed to carry on doing what they had been doing before because the trust couldn't afford the necessary number of PAs (or because it was illegal.

    The whole NHS runs on goodwill, not just the GP land.

    Yes, the hospitals have some glaring inefficiencies but it is really shameful that you suggest the hospital docs are not working their backsides off like the rest of us.

    Don't forget that within the admin PAs they have to teach the juniors, organise rotas, teach GPs, and do all the admin stuff we have to do (but without the advantage we have of being much more efficient due to having decent computer systems).

    The comparison of money spent in hospitals per patient contact is also utterly nonsensical. This is apples and pears. I would need a lot more money if I was going to be doing open heart surgery on my patients, just as I would need a significantly bigger drug budget if I was going to be in charge of oncology drugs or new biologics.

    Stop being so negative and lets all draw together for the sake of the patients and the NHS. We should be fighting privatisation and fragmentation, not each other.

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