The Future Of The NHS

Seasonal Affective Disorder – You know it's getting bad when you look at the blank, white page of your blogging software and your mind just shuts down.


So lets tell you about the future of the NHS, and how it's going to drive me crazy.

On my patch we have a hospital. This hospital has two buildings, one is the traditional hospital that all UK residents know and love, corridors, wards, doctors, porters, nurses, radiologists and others walking around. Slightly grubby, dodgy café, doctors running clinics.

The other building, 400 yards down the road is shiny and new. It is 'nurse led', there are posh coffee bars, the floors and walls are clean. Not much in the way of wards, but this building is only supposed to be used for day-case surgery. Nurses run the clinics and there is a sculpture outside. This is the future of the NHS, a pre-polyclinic polyclinic.

Which is why I'm surprised to find myself responding to a standard 'chest pain' inside this building.

The patient is there to see one of the nurse clinics, she develops a bit of chest pain and the first thing that the nurse in charge does is dial 999 for an ambulance.

I get there second as one of our FRUs was parked within sight of it. As I enter the room, not only have they moved the patient (resulting in us having to do a bit of searching) but there is a bit of a flap going on.

You se, a doctor has been called and he is panicking. He's shouting orders to the FRU, orders which could be extremely dangerous (for the medics in the audience he wants us to give GTN/NTG before checking a blood pressure). Our patient is sitting quite happily in her wheelchair watching our FRU take quiet control of the situation.

This is an absolute 'meat and potatoes' call for us, we deal with this sort of thing day in and day out – just by observing the patient and listening to her we suspect that it isn't her heart that is causing the pain.

But the doctor is screaming about getting 'crash carts' into the room and the nurses are running backwards and forwards like headless chickens. A manager from the other site arrives looking flustered – they confide in me that they turned up because they were worried about what these staff 'were up to'.

After a little more kerfuffle we wheel the patient down to the ambulance, do an ECG (which is normal) and transport her the very short distance to the A&E department where, after some more ECGs and blood tests, is diagnosed with indigestion.

I'm reminded of my nursing days when I saw a GP doing the world's worst CPR on a woman who had pretended to faint – I would have thought her trying to fight him off may have given him a clue that it wasn't a cardiac arrest.

This isn't a post about daft doctors and silly nurses though, after all if I were called upon to anaesthetise someone I'd certainly make a pig's ear of it. We do have our own area of expertise and I can't expect everyone to be as expert in the emergency treatment of chest pain as myself.

But.

This was a 'nothing' call, even without the benefit of hindsight – but as it was seen as an 'emergency', the best thing that the staff could think of was to call and ambulance and then a 'crash doctor' (and heaven alone knows why he was the only one to turn up, perhaps that's all they have staffing the crash team).

This points to there being a distinct lack of planning around what happens when something unusual happens, I'd dread to think what would happen if the patient had suffered a full cardiac arrest – they would have been little better off than collapsing in the street.

So, this is the future – you go to the nice, clean, artistically designed hospital for a minor treatment – but if you have a serious complication or something untoward happens the first thing they'll do is call for two blokes in a clapped out van.

Maybe it's just cheaper to 'outsource' emergency care to the ambulance service, maybe the next big thing for the NHS will be ambulances being called to deal with in-hospital cardiac arrests because then you won't need to pay for a full 'Crash team'.

I'm hopeful that somewhere in the planning for this 'healthcare centre' a manager getting paid a serious multiple of my pay-packet didn't think, 'well, if there is an emergency we can save money by just calling for an ambulance'.

I hope.


Almost completely unrelated – my mum went to her hospital a few days ago and was told by a doctor that she should 'drink lots of water so that she doesn't catch diabetes', at which point she walked out in disgust. The same doctor recommended physiotherapy for something that would only be made worse by it. So its not just me that sees this sort of thing.


Even more unrelated – does anyone know a good (or want to set up a) heavy RP guild on Warhammer:Age of Reckoning Ellyrion EU server? Edited to say *Obviously* for the side of Order…

28 thoughts on “The Future Of The NHS”

  1. Yeah, I really need to invent the *irony* tag to make it obvious when I'm trying to be a bit funny…(So, no, I'm not an 'expert' but I do think I'm *certainly* more expert than the many GPs who sit their ACS/MI patients out in the waiting room to await the ambulance. Which, round my way, is shamefully commonplace – and when I challenge the GPs on this they have no reply).

    However, an interesting point – when the service brought in the pilot of ambulance staff reading ECGs they tested road crew recognition of STEMIs against A&E SHOs. The ambulance staff scored higher.

    On two separate occasions.

    We audit the people that we do ECGs on and we have 100% recognition, so in the recognition of STEMIs we are quite good.

  2. OK doc, let's get nasty and cynical here. let's suppose you, being a doctor (I presume), ignore the guidelines you have been given and dose your patient and that patient dies as a result. What will happen to you? On past observation, not a lot. Your colleagues will unite behind you – they've all been in fraught judgement calls themselves – the MDU will bare its well honed teeth and there will be a lot of talk about the importance of independent clinical judgement, honest mistakes, stress because of excessive hours of work, and the like. You will have to live with having killed a patient, but professionally you are unlikely to suffer much.But a nurse or a tech who acted thus? As well as the personal guilt, they will be hung out to dry. Their colleagues, whether sympathetic or not, are probably going to keep their heads down. Their professional associations will disown them. They will lose their jobs and be vulnerable to civil and criminal charges which, unlike doctors, they will not walk away from with a slap on the wrist.

  3. The point being Charles is that we are not given “guidelines” for things like measuring BP pre GTN. We are given 5 years of full time undergraduate training followed by years of postgraduate training. We are expected to know the pharmacology of the drugs we give, the pathophysiology of the conditions we are treating, and then to treat as appropriate. If the medication or treatment we administer causes side effects, we are expected to know how to deal with them.And I really do not know where you get this impression that there is still a doctor's club where the incompetent are never punished-

    http://www.the-mdu.com/Search/index_title_0.asp?usertype=studentm

    http://www.gmc-uk.org/concerns/hearings_and_decisions/fitness_to_practise_decisions.asp

    not to mention numerous legal proceedings.

    I think this disparity that you perceive in treatment of nurses/techs/other paramedical staff vs doctors belies a misunderstanding about roles. The very fact that protocols exist for drug administration by ambulance service staff, nurses etc, is because those that are giving them are not trained to understand the entire pharmacology, interactions, contraindications- therefore there HAS to be a tick-box process to make the process as safe as it can be. Taking the GTN example again- ambulance staff must follow their protocol (measuring BP) or risk, as you say, being 'hung out to dry'. Doctors, on the other hand, knowing the exceeding short half life of GTN, coupled with the ability to treat hypotension effectively should it occur, know it makes bugger all difference whether or not they measure the BP first, but know they do it anyway at some point as part of their diagnostic process.

    And to Paula- I am not a troll, and I apologise all round for the flavour of my first post, it was a little excessively sarcastic. However I find it incredibly frustrating that the world and his wife think that being a doc is an easy job, half of us are idiots anyway, and hey- even if we do kill a few people, the old boy network will protect us ! Medicine is NOT tick box, protocol-driven, 'test x means this is diagnosis y' despite what the government will have everybody think. Diagnosis and treatment are difficult, and for every decision you see a doctor make, be very sure there were multiple other thoughts and options they considered before making the choice they did.

  4. Why would you pay for a crash team? They're just doctors dragged away from their day jobs.(Not that responding to crash calls isn't important, but on a busy day other important jobs for the punters in A&E and on the wards can fall by the wayside)

  5. Bloody Hell “Catch Diabetes”. And there was me thinking it was a chronic condition, caused by varying factors – I'm definitely not looking forward to winter; I might slip on the ice and “catch” one of those nasty broken legs!

  6. I get more concerned about the doctors and nurses flapping than not quite hitting the nail on the head.I don't know what is in place in terms of placement or requirements but maybe having all newly qualified doctors and nurses doing a year in an A&E department mixed with 3rd manning on the road with us green suits every so often would help with this “Oh my god! Call an ambulance” culture from GP's.

  7. I think treatment priorities in ?MI differ vastly between prehospital care and hospital care (and between different agencies of the same).In one hospital I've worked at, it would be standard practice to give GTN straight away, without a blood pressure, probably even before oxygen. I've never seen that go wrong (let's face it, you usually have a pretty good idea if a patient was severely hypotensive enough for GTN to cause an adverse effect without actually taking their blood pressure, and in any case regardless of blood pressure nitrates to some degree are still indicated). If it did, by some sheer fluke of nature, go wrong, you have the staff and equipment to deal with it instantaneously, which you don't necessarily have pre-hospital.

    Whereas in prehospital care, the focus does very much tend to be on oxygen, then aspirin, then obs, then ECG, then nitrates and finally opiates.

    I don't necessarilly think that either approach is best, although from a patient comfort point of view it has to be kinder to give the GTN as early on as you can.

    There is a strong case for more thought to be given to how best to handle in-hospital emergencies though. Whilst the response here was clearly poor, even in the nice traditional hospital you talk about, I bet the response isn't that great. Research has shown time and again that management of resuscitation and acute events in hospitals is absolutely dire, no matter if it's done by a junior doctor, a senior doctor, a nurse or a passing porter. That's the real story here, and one which ought to be publicised more. If the public knew the level of incompetence and poor planning surrounding this area, there'd be an absolute uproar.

  8. random responses….one, I wonder if that nurse hospital had policies about this? like, ordering the nurse to dial 999 if faced with a perceived emergency (such as a reported chest pain)? Oh yes, it could be. In our local cottage hospital, a young woman turned up about to give birth, with no hope of getting to the nearest maternity unit in time. There were several qualified midwives on duty, but as they were employed as nurses, not currently on the midwives' Register, they daren't act as midwives and had to haul in a paramedic to do the honours.Second, make allowances for temperament. There are just those who can't cope with the acute, doctors as well as nurses. Sensibly, they normally gravitate to areas of medicine, such as dermatology or occupational health, where they need never see a cardiac or respiratory emergency from one year to the next. I suspect your clinic nurses might fall into this category. It takes all sorts – I cannot imagine working in a geriatric hospital, for instance, but some people thrive on it, fortunately.

  9. Seems to me the nastiest contagious disease in NHS hospitals is a brainless adherance to the latest fad (ORCON, poly clinics etc)..

  10. “maybe the next big thing for the NHS will be ambulances being called to deal with in-hospital cardiac arrests”Been there, done that. 999 call to a cardiac arrest in a hospital clinic, 150m from A'n'E, 'bout two years ago.

  11. Been sent to at least 3 arrests on hospital wards. Worst is a certain OOH GP clinic located 50 yards down the corridor from the A&E who still call 999 – and our lot still send!

  12. Charlesdawson 18:43 “There are just those who can't cope with the acute, doctors as well as nurses.”As a member of a 'Voluntary Aid Society', I am aware that many professionals could 'cope' – but have honest concerns about 'governance' , especially if they act outside of their special areas of expertise, or without the full range of staff & equipment.

    See also the survey in 'Nursing Times' in September – //three-quarters of nurses would be worried about the legal risks of intervening in a public emergency and as many as 13% would therefore avoid doing so.//

    http://tinyurl.com/5av6hu

    Or – as a dad said to me whilst I was assessing his daughter who had fallen off her horse – “I'm a Consultant Clinical Psychhologist – what do I know about trauma?”

  13. i seriously doubt any doctor would think you can catch diabetes. maybe your mother misheard/misunderstood!! i hear a few family get annoyed about medics when its their own ignorance thats the problem. eg someone i know went to A+E with knee pain (no trauma, just general arthritis likely) and moaned that the A+E nurse was rubbish as she didnt x-ray him and sent him home without seeing a dr. now any sensible person knows there was nothing this poor nurse could have done for him and that he needs to see his GP.so why the dr bashing? i could paramedic bash and say my father collapsed recently but the arrogant paramedics said it was a panic attack (???) and didnt send him in to A+E. now thats stupidity, who do they think they are to think they have the knowledge base to decide this???????

  14. You may be surprised at what *some* doctors think, they have their fair share of crazies like everyone else. And yes, my mum did check what he had just said.To be honest there are crap doctors, nurses, ambulance staff, radiographers and so on and so forth. There are the Beverly Allits and the Dr. Shipmans no doubt still dotted around the NHS.

    Which is why I restrict my criticism to either individuals or to the policies that create the situations that lead to idiocies.

    (Most ambulance crews will take everyone to hospital, as we don't like the idea of being sued when it al goes horribly wrong and I'd say a fair few of us have no problems in recognising where our competencies end. Having said that, there are bad ones out there and I hope that your father was alright).

  15. alas, uncle john, there are still a proportion who panic. in my days as an itu nurse I have known nurses from the general wards refuse even to enter the door of the unit, so unnerved were they. didn't ER have an episode some years ago where management of the US hospital decided to “break” those coming up to their pensions by forcibly transferring them to A&E work in the hope that they would resign? apparently based on fact, that.the worst panickers in my experience are occy health nurses (fifty-seven enraged occy health specialists will now flame this forum).

    mind you, that said, if I were a victim, sorry, patient, I would rather deal with someone who honestly admits they are out of their depth, rather than some cocky little twit who charges in and makes bad worse.

  16. i agree there are crap ppl in every profession. guess it just gets annoying when you hear nurses/midwives etc slag them off when its blatantly obvious they have a chip on their shoulder. (im a final year medical student)yeh my dad was ok, but when i found out recently i was bloody damn annoyed cos if the paramedic had taken a proper history he would have realised my father isnt known to have stress, or Sx of hyperventilation etc , he just turned his head (he has cervical spondylosis it turns out compressing his vertebral artery).

    i hear some ppl telling horror stories about some drs, like what ur mum said, i just find it so hard to believe these ppl would be allowed to graduate and get thru the system.

  17. How come there be doctors be qualified , and still be not competent.Tis the bell curve of reality. The band of fantastic doctors at one end at tother, those that should be struck off the list.Not all that regurgitate the text word perfect, be able to practice the ART of medicine and then there are many that barely get all the details of the text regurgitated, are fantastic at fixing the broken body.'Tis why Lawyers make fantastic monies in medical stupid fatal mistakes , but the old boys club is strong to prevent club fees being suspended. Back in the 1600's it was better not to see the doctor , in many cases ye lived longer, thankfully it has improved since days of blood letting.It also be known that there have been practitioners of the Art of Medicine that have never passed the test, but were successful in not killing their patients but have been fully accepted by their patients as very good.There many Diploma mills around, and not all schools of Medicine turn out top notch practitioners of of the ART.Buyer beware:

  18. Tom, you are being a tad arrogant with this post! You are most certainly NOT an expert in management of chest pain – or have you become a consultant cardiologist overnight.Your post actually is typical of the problem with the 'modern' NHS – that nurses/paramedics/health care assistants etc all think they can do the job of the doctor. I garuantee that your 'expertise' in the pathophysiology of chest pain is not nearly as good as your average A&E middle grade!

  19. Wow this is so scary, added to which we are paying for this!Why is the NHS so difficult to sort out? It gets so much money thrown at it – what other business is in such a luxurious position.

    Off topic slightly- my neighbour has terminal lung cancer, she has to go to hospital periodically to get fluid drained off her lung. Whilst there she benefits from receiving oxygen as it helps her breathing. She tells me the nurses leave the oxygen spurting out, even when not in use. She has asked they turn it off, seems a waste, but they reply don't worry we are not paying for it! She argues but we are!! Seems some sort of financial awareness training would be of benefit!

  20. You do not need to wait for a BP before giving GTN, unless the patient is dancing the macarena around the department. In which case, they probably don't need the GTN either. Why would the patient be hypotensive anyway? In the setting of chest pain, potentially the patient is in caridogenic shock, that is, the heart is failing to pump adequately because of ischaemia. This may be exacerbated by pain, which produces tachycardia, which worsens ischaemia. Why? Well, as I'm sure you already know Tom, the coronary circulation fills in diastole, and a tachycardia will shorten this interval. If the patient is hypotensive because of cariogenic shock, then GTN will reduce pre- and afterload, perhaps allowing the patient's heart to pump more efficiently, as Starling's law dictates. But you knew that didn't you Tom?As regards to ECG changes in chest pain, how many first ECGs are normal in acute MI? Do you know THAT one Tom? *

    If my family member has chest pain, please don't fanny about spending 20mins on scene doing ECGs, BPs or attempting a diagnosis. Please take them immediately to the big building marked 'hospital' with people inside who are trained to diagnose.

    *Up to 30% of people with acute myocardial infarction have a normal ECG. A single normal ECG means JACK ALL in the setting of chest pain

  21. The reason why I wait for a BP is because (a) The BNF lists hypotension as a contra-indication and (b) Because our Clinical Director (who is a doctor) tells us to.Why would they be hypotensive? Well maybe not because of their current illness, but maybe due to anti-hypertensives, perhaps they'd taken Viagra, perhaps some other reason – you don't know until you check after all.

    And I can check a BP in under 30 seconds, having been trained many years ago with manual BP cuffs.

    And yes, I *do* know about Starling's law, having been an A&E nurse. I also know that an ECG isn't definitive to rule out an MI. I can also quote you the times that the various enzymes show up in the blood tests.

    I do however find it disingenuous that you would want me to do nothing other than be a 'fast taxi' for a relative with chest pain, I take it you wouldn't want a STEMI going to an angioplasty centre but instead to a bog-standard A&E.

    Except of course that Angioplasty is the gold standard treatment for this sort of thing, but then you wouldn't want us trying to spot ST elevation would you? After all isn't that stepping on the territory of doctors – how about defib? Should we stop doing that as well?. (And see another reply of mine for our 'success rate' on STEMIs, hint – it's 100%).

    And one last thing, being fully aware that ECGs are not definitive we 'blue in' all suspected cardiac chest pains while giving GTN and aspirin (but not always oxygen now because of the British Thoracic Society's new guidelines).

  22. Oh dear EDdoc, you really are out of your depth aren't you? A single normal ECG in the context of chest pain does indeed mean jack all. A single ABnormal ECG in any context that shows a barndoor MI means the patient is then transported not to the big building marked 'Hospital' but to the big building marked 'PCI' (look it up if you don't know what it means) where they will be seen by people who unlike you are extremely well trained in the diagnosis and management of chest pain. That seems to me a pretty good reason for training paramedics in ECG interpretation. If like me you had ever looked after a patient in cardiogenic shock you would know that the only adverse sign is often a low BP. I would not recommend giving GTN to this type of patient (because they will die). You don't reference your claim that 'up to 30% of patients with AMI have normal ECGs'. This is nonsense. You may be referring to research about Troponin as a marker for AMI which is quite a different thing. For the record I am an A&E nurse in the same neck of the woods as Tom and if you were really a A&E doctor and gave a patient GTN without knowing their blood pressure, I would inform your boss, complete an incident form and email your consultant and quite possibly remove you from duty for imcompetence if I happened to be in charge. GTN is a useful drug in the treatment of chest pain caused by ischeamia but if your family member has chest pain I would insist on an ECG, some baseline obs (how long does that take?), some Aspirin, GTN and anagesia if indicated. This might well take 20 minutes but it is 20 minutes well spent.I am amazed I managed to reply to you without losing my temper considering it was such a troll like response.

  23. Dear Paula, here's a few references for you, peruse at your leisure.http://www.bestbets.org/bets/bet.php?id=75

    Am also intirgued to hear about a patient with cardiogenic shock, quite happily sitting up in a wheelchair, who'll die with a dose of GTN. You don't reference your claim – would you mind doing so for my education? I'm also concerned that my grandma doesn't have a BP monitor at home, yet has a diagnosis of heart failure and angina, and uses GTN. I am deeply concerned she may self administer GTN without knowing her own blood pressure and die!

    Although she does have a nice house which i've had my eye on for a while – perhaps I should suggest she has TWO puffs of GTN next time, just to finish her off? (could I have one of those irony tags please tom, just in case paula reports me to the GMC for having a murderous nature).

    Checking BP all well and good if there's a sphyg handy, otherwise a conscious patient who doesn't look white, and has a decent pulse would be fine for me. 🙂

    Jon

  24. Thanks eDoc for your explanation. I agree that the word “guidelines” was too narrow/loaded a description of what happens; nevertheless, there are constraints on doctors' prescribing, such as BNF, individual drug data sheets, other pharmacological literature, what your consultant likes/dislikes, what NICE will permit and so on and so forth. That range of constraints is what I carelessly subsumed under “guidelines”. Should you consider them negligible?I am a bit bemused myself that you, in turn, assume a lack of depth knowledge on the part of other professional specialists. Indeed, this is the whole point of specialised technicians and nurse practitioners: they do have detailed knowledge and extended training, but of necessity within limits; and within their specialist areas, believe it or not, they may well have considerably more knowledge and expertise than, dare I say, your average SHO, even if s/he did get trained at a University.

    As to the protection of doctors' club, the derivation comes from over 20 years observation of the phenomenon while working in the NHS as a nurse and technician. I did not say, nor wish to imply, that all or even most doctors are idiots with a soft job – after all, if it was that easy we'd all be doing it, wouldn't we?

    Nor do I wish to imply that it is the medics who take their errors lightly, on an individual level. At least, the young lady who recently prescribed a patient of mine 400mg frusemide was very grateful to have the amount queried.

    I have seen many an incident – and no, I can't supply you with published references, since publicity was the last thing anyone involved wanted – when the sequel to errors involving both doctors and nurses/technicians resulted in the former continuing to practise unhindered at the same time as the latter were suspended, officially investigated, and in some cases penalised.

  25. reminds me of when I finished medical school. The dean of our faculty who was our physiology professor (non-medical) and used to smoke like a chimney, said on our last day as undergraduates:-“…and when I have my heart attack, no one is to move. No one is to move. You all stay in your seats and wait until a qualified ambulance officer arrives!”

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