The Grand NHS Experiment (based on rationalisation and logic) of the last decade (a.k.a. the 4 hour target) has already proved to be a waste of time, why should this be any different?
The Grand NHS Experiment (based on rationalisation and logic) of the last decade (a.k.a. the 4 hour target) has already proved to be a waste of time, why should this be any different?
Dear Editors
Dr David Oliver wrote in his article:
"Here are some suggestions on how we might tackle the problems, but I’m hardly alone in making them.7 8 9 They aren’t all supported by robust evidence but may lend themselves to pragmatic local improvement studies in real time.10 And I don’t pretend that we can afford or reliably implement them all, but we should surely try:
Have senior decision makers at the front door, and rapid ambulatory alternatives, to get more people straight home sooner, avoiding transfer to deeper wards. Early specialty input could ensure expert management and get patients rapidly diverted to outpatients or directly admitted to a specialty ward."
Dr Sunku Guptha in the rapid response of 24 Sept 2016 correctly countered this argument:
"For instance there is a great emphasis on senior decision makers at the front door so patients can be given appropriate treatment and discharged promptly avoiding an admission. Rotas across the country now have consultants at the front door from 8AM to 10PM every day of the week. The conversion rate for admissions has however continued to rise (figure 1)"
and
" It is frustrating that after sustaining this initiative for a long time there is little if any impact on admission rates."
Whereas Dr Oliver wrote in his rapid response to Dr Gupta including various suggestion while data between variations in hospitals and conversion rate is "too big" and complex to detect any impact and that:
"it beggars belief that any doctor could be arguing "we as highly trained professionals value add to patients care" and then simultaneously argue that it's OK not to see senior decision makers early during admission and wait till a couple of days later. Or that it's OK to have that access decided by whether you arrive mid afternoon or early evening. Most doctors, if they or their family presented acutely to hospital would choose for themselves to see someone senior sooner rather than later"
I would like to remind Dr Oliver in the era of Evidence Based Medicine, NHS-wide austerity measures as well as staffing shortage, the use of rationalisation and logical thinking to account for the lack of good evidence will ultimately fail. We all seen that happen in our time: the grand 4-hour-target "experiment" which is based on some good idea and "common sense" and logical thinking but ultimately lead to nowhere.
Thus before we accept that "Is that a world we really want to go back to just because conversion rates haven't changed?", unless there is other evidence like improved mortality etc from this new staffing arrangement in some hospitals (which was meant to help), it is foolhardy to expect real benefits if this is to be extended to other facilities.
Otherwise we will hear these excuses in the future on this:
"It's only gone wrong because of heavy cuts in staff and budget which have stretched supervisory resources beyond the limit" *
or
"It was a worthwhile experiment now abandoned, but not before it provided much valuable data and considerable employment"+
(*The Comprehensive Schools Excuse and +The Concorde Excuse from The Complete Yes Minister, p. 338)
And by the way, while Mr Stephen Black suggested more can be done with IT systems to reduce delays, including the fact that "Too many hospitals don't seem to realise, for example, that long waits in A&E are caused primarily by failures not in A&E but in the way discharges from beds are managed", I guess it may be timely for Mr Black to know this fact that the A&E bed number may not have reduced over the last 5 years, ward bed numbers certainly did in NHS England; having lost 10,000 beds (10%) in 5 years, of which half of them are acute/medical (5% total) (Ref 1).
Pretty hard to anyone to hit the target while the target size keeps getting smaller.....
Reference:
1. NHS England bed Availability and Occupancy Data – Overnight since 2010-11 onwards
Rapid Response:
The Grand NHS Experiment (based on rationalisation and logic) of the last decade (a.k.a. the 4 hour target) has already proved to be a waste of time, why should this be any different?
Dear Editors
Dr David Oliver wrote in his article:
"Here are some suggestions on how we might tackle the problems, but I’m hardly alone in making them.7 8 9 They aren’t all supported by robust evidence but may lend themselves to pragmatic local improvement studies in real time.10 And I don’t pretend that we can afford or reliably implement them all, but we should surely try:
Have senior decision makers at the front door, and rapid ambulatory alternatives, to get more people straight home sooner, avoiding transfer to deeper wards. Early specialty input could ensure expert management and get patients rapidly diverted to outpatients or directly admitted to a specialty ward."
Dr Sunku Guptha in the rapid response of 24 Sept 2016 correctly countered this argument:
"For instance there is a great emphasis on senior decision makers at the front door so patients can be given appropriate treatment and discharged promptly avoiding an admission. Rotas across the country now have consultants at the front door from 8AM to 10PM every day of the week. The conversion rate for admissions has however continued to rise (figure 1)"
and
" It is frustrating that after sustaining this initiative for a long time there is little if any impact on admission rates."
Whereas Dr Oliver wrote in his rapid response to Dr Gupta including various suggestion while data between variations in hospitals and conversion rate is "too big" and complex to detect any impact and that:
"it beggars belief that any doctor could be arguing "we as highly trained professionals value add to patients care" and then simultaneously argue that it's OK not to see senior decision makers early during admission and wait till a couple of days later. Or that it's OK to have that access decided by whether you arrive mid afternoon or early evening. Most doctors, if they or their family presented acutely to hospital would choose for themselves to see someone senior sooner rather than later"
I would like to remind Dr Oliver in the era of Evidence Based Medicine, NHS-wide austerity measures as well as staffing shortage, the use of rationalisation and logical thinking to account for the lack of good evidence will ultimately fail. We all seen that happen in our time: the grand 4-hour-target "experiment" which is based on some good idea and "common sense" and logical thinking but ultimately lead to nowhere.
Thus before we accept that "Is that a world we really want to go back to just because conversion rates haven't changed?", unless there is other evidence like improved mortality etc from this new staffing arrangement in some hospitals (which was meant to help), it is foolhardy to expect real benefits if this is to be extended to other facilities.
Otherwise we will hear these excuses in the future on this:
"It's only gone wrong because of heavy cuts in staff and budget which have stretched supervisory resources beyond the limit" *
or
"It was a worthwhile experiment now abandoned, but not before it provided much valuable data and considerable employment"+
(*The Comprehensive Schools Excuse and +The Concorde Excuse from The Complete Yes Minister, p. 338)
And by the way, while Mr Stephen Black suggested more can be done with IT systems to reduce delays, including the fact that "Too many hospitals don't seem to realise, for example, that long waits in A&E are caused primarily by failures not in A&E but in the way discharges from beds are managed", I guess it may be timely for Mr Black to know this fact that the A&E bed number may not have reduced over the last 5 years, ward bed numbers certainly did in NHS England; having lost 10,000 beds (10%) in 5 years, of which half of them are acute/medical (5% total) (Ref 1).
Pretty hard to anyone to hit the target while the target size keeps getting smaller.....
Reference:
1. NHS England bed Availability and Occupancy Data – Overnight since 2010-11 onwards
Competing interests: No competing interests