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Acute care doesn’t always go with the flowchart

Acute care doesn’t always go with the flowchart

Dr Copperfield on ICSs trying to overhaul acute care 

You only have to witness one day duty surgery to realise that we GPs are masters at creating order from chaos. So we can relate to ICSs’ attempts at trying to overhaul acute care. They’re trying to do on the macro what we do so successfully on the micro.

There’s two problems, though. There’s the obvious one about putting up barriers around A&E in the form of an appointment-only service. Our reflex – and probably correct – response to this is that it means work is diverted our way. That said, with current A&E waiting times, a slot in three days for that compound femoral fracture feels like a result.

The other issue is the assumption that, to put out acute fires, you need flowcharts rather than firefighters. This is a big mistake. On-the-day illness is full of uncertainty in presentation, notoriously unpredictable in progression and experienced by patients who are frightened and – durr – feeling ill. These patients are therefore not functioning at their best. An unclear start point, variable direction of travel, and confused patients mean protocols crumble immediately.

Chuck in the mandatory digitalisation of everything and you don’t have a patient pathway; you have a highway to hell.

Take the pathway highlighted in the Pulse story above for exacerbation of COPD. Just play the role of a hypoxic patient for a moment. Have you got end stage COPD?! Are you getting worse?!! Go online via your GP website (click ‘COPD’) or by accessing an iPad at your neighbourhood health hub!!! Complete a short online form!!!! Wait for a text with either self-help advice and a community health worker or an invitation to a face to face appointment!!!!! Then wait for a call to confirm all the above!!!!!!

What could go wrong? It almost makes being seriously ill fun.

One end point in this flowchart is, ‘Discussing… what a good death looks like’. Trust me, it looks nothing like this. A good death in COPD does not involve neighbourhood hubs, iPads and texts. It involves hand-holding, morphine and continuity. It’s your GP, not ChatGPT.

So good luck, ICSs, with your attempts at sorting out acute care. I just wonder if you’ve asked the right people, those with the superpowers. Because there is something dying here – and it’s not just patients with COPD.

Dr Tony Copperfield is a GP in Essex 



Please note, only GPs are permitted to add comments to articles

John Cormack 3 July, 2024 10:19 pm

You say a good death does not involve neighbourhood hubs, iPads and texts. I agree. A patient whose husband was dying told me that she had at least 20 visitors during the course of the day – that may have been a slight exaggeration but I believed her 100% when she said: “There were so many I ran out of teacups.” They all introduced themselves cheerily on arrival: “Hello I’m Jennie. Hello I’m Justin.” Each of them explained their various roles. She said they then proceeded to chat happily amongst themselves and very little of use came out of it. By 5pm they’d all disappeared leaving her to fend for herself. The Marie Curie nurse didn’t turn up – so, as I’d given her my number, she rang me. Then, as you say, it was a case of hand-holding, morphine … and continuity of care.

So the bird flew away 3 July, 2024 10:39 pm

Great takedown of this shitty flowchart for a+e care. Nothing funny to find in this story except apparently these are the same management wonks who struggled to design a flowchart for how to have a piss up in a brewery!

Some Bloke 8 July, 2024 4:47 pm

delivery of treatment should be led by most senior clinicans, in the community it would be a GP, in hospital or MH trusts- a consultant, with rest of services supporting clinicians. here we have a complete opposite: lots of fuzz and buzz and very little sentior clinical input (unless it’s in GP surgery). what could go wrong I wander?

Truth Finder 12 July, 2024 10:06 am

Protocols and flowcharts are done by non practicing clinicians and economists. What could go wrong!