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Back in the trenches

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?