How medicine now works – or doesn’t.

It may surprise some of you that read this blog that, amongst other things, I still work as a doctor in the jolly old NHS. Yes, one can be a critic and still remain inside the system….although for how long, who knows. In fact, in some ways I am quite establishment, as I sit on the main BMA negotiation committee for GPs, the General Practitioners Committee (GPC). I am also on the Local medial committee (LMC) and local negotiation committee (LNC).

From within the NHS you can more clearly see how the world of medicine is gradually going completely bonkers.

In one of my jobs I do Out of Hours (OOH) General Practice work. That is working in the evenings and weekends. In East Cheshire, where I work, we had a system which was highly rated by patients and everyone who came into contact with it. However, in line with the rest of the country we were told we were now to be incorporated into the Government’s latest and currently stupidest idea, called NHS111. The 111 bit being the single telephone number for people to call for urgent – not 999 care.

NHS111 call handlers get about six weeks training, and are supposed to act as front line troops to direct patients to the correct urgent service. Before this we had nurse triage, with experience nurses dealing with local residents and their health issue. We now have non-medically trained staff given superficial advice on how to go through a treatment algorithm. First question:  ‘Are you alive or dead?’ Not quite, but nearly.

At the end of asking ten thousand questions, or so, the call handler reaches the end of the algorithm where it states ‘You must see a GP.’ Actually, not quite true.  If there is anything actually wrong,  then the call handler tells them to phone an ambulance immediately [Yes, ambulance calls under NHS11 have risen stratospherically]. In my opinion, these people are not doing triage, they are just appointment Clerks.

As we repeatedly warned the Government NHS111 rapidly went wrong.  In East Cheshire and many other areas, NHS111 immediately collapsed the moment it went live, and we had to take back all the call handling. Why, primarily because the private providers running the service had so badly underestimated demand that the system went into melt-down, and patients were left waiting for hours to be called back. (Oh the joys of competitive tendering. In order to get the contract you have to bid so low that you cannot actually provide the service).

Anyway, we still get some calls coming through from NHS111 (A system now running in parallel – at double cost – with the old system).  With the old system we used to get the key facts e.g. a rash, non-blanching, child floppy, temp 39oC, mother worried. Now we get the following (this is an actual transcript of a very, very  simple case, with any patient identifiable data taken out – by me).

  • Symptoms: Cough
  • Case Summary
  • Disposition: The individual needs to contact the GP practice or other local service within 6 hours. If the practice is not open within this period they need to contact the out of hours service. Dx06
  • Selected care service: OOH – GP OOH Service (xxxx Base)
  • Pathways Assessment: Birth had not occurred within the last hour. An injury or health problem was the reason for the contact. The individual was breathing and conscious at the time of the assessment. Heavy bleeding had not occurred in the previous 30 minutes.
  • An illness or health problem was the main problem.
  • The individual was not fighting for breath.
  • A probable allergic reaction, a fit within the previous 12 hours or successful resuscitation were not the main reason for the assessment.
  • The child was not limp, floppy and/or unresponsive.
  • The skin on the torso felt normal, warm or hot.
  • Pathway selected – Cough
  • The individual had not coughed or vomited blood.
  • There was normal breathing between bouts of coughing.
  • Severe illness and a rash suggestive of septicaemia were not described.
  • There was no difficulty rousing.
  • There had been no episode of choking within the previous 24 hours.
  • There had been no inhalation of a hot or poisonous substance in the previous 24 hours.
  • There was no fever at the time of assessment or within the previous 12 hours.
  • There had been no previous diagnosis of heart disease, asthma or other lung disease.
  • There was not a problem for which medical advice must always be sought.
  • There were no severe coughing bouts with whooping, a red or blue face or vomiting after coughing.
  • The cough for had persisted for less than 3 weeks.
  • Instructions given were: The individual needs to be seen
  • by the GP practice or other local service within 6 hours.
  • If the practice is not open within this period they need to be seen by the out of hours service.
  • Directory of Services referral: OOH – GP OOH Service (xxxxxxx Base)
  • Advice given: Worsening
  • Advice given: If the condition gets worse, changes or if you have any other concerns, call us back.

As you can see, if you bothered to read it, 99% of this is just meaningless guff, stating irrelevant negative findings. But it does take a considerable amount of time to read. Some of it just made me despair. For example, the report states that: ‘An injury or health problem was the reason for the contact.’ Well really, how completely amazing. Someone calls a health line and they may have an injury or health problem.  Who’d a thunk?

This is followed later by…’ An illness or health problem was the main problem.’ Well at least they had narrowed it down from an injury or health problem to an illness or health problem. [So it now seems that illnesses are not health problem?]

What did I actually need to know? I needed to know that a child had a cough that was getting worse. Whilst it is possible to establish this from reading the report (just)  other key information was conspicuous by its absence. Past history of asthma, for instance (which this child had) or other respiratory problems? Any medications?  That type of thing.

As with most new initiatives in the health service I am now getting swamped with information – but the vast majority of it is completely and utterly useless, and just gets in the way of finding out what I want to know.

This, by the way, was a very small part of the report that the GP (in hours), will receive. They will get about ten more pages of other extraneous guff that they have to wade through. At some point my consultation (the only bit they are interested in) will appear so they will know what I found and what I did – and if they need to do anything. This will not be at the front of the report, no, it will be stuck in the middle, surrounded by information about when the call came in, how long it took to respond, what pathways were used etc. etc. etc. thud.

This, ladies and gentlemen, is the type of nightmare bureaucrat driven nonsense that is turning healthcare in the UK from something local, flexible, and responsive to patient needs, into a flabby form filling, algorithm following, arse-covering exercise. Millions of hours spent producing lengthy reports that have no value; they simply get in the way of providing useful information and de-skill, demotivate and de-professionalise everyone involved.

I imagine the UK is not alone in this. Somehow or another we need to fight back.

25 thoughts on “How medicine now works – or doesn’t.

  1. Lorna

    When you compound this nonsense with what is going on elsewhere in the public services, we must be losing money from State services to the private sector at an appalling rate. Education is just one example: more managers than we can find jobs for and larger classes for teachers (see debate about the reduction in staffing at pre-school level). Depressing! Still, knowing others can see the stupidity too goes some way to making me feel vindicated in my opposition to the political process of telling professionals they no longer know how to do the job they were trained for and handing the job over to short-term contracts and low wages.

    1. Dr. Malcolm Kendrick Post author

      Yes, I am absolutely certain that this is going on everywhere. You train for years and years, then some idiot who knows nothing of what you do listens to the siren song of the McKinsey consultant who has but one thought. Competition and the free market will magically make the world shiny and new….bippity boppity boo. Oh shit, it broke. What we need is more free market and more competition… Oh shit, it broke again. What we need…..Oh please do shut up and piss off to Verbier to ski.

      1. Richard

        I don’t think this is the fault of “McKinsey consultants” necessarily – their job should be to observe the system in operation, locate inefficiencies, and propose process improvements; they should be on your side, trying to allow you to do your job more efficiently! Surely it’s ideological policy-makers that advocate competition in all areas?

        1. Dr. Malcolm Kendrick Post author

          Well, I’ve spoken to several McKinsey people, and listened to them talk about the NHS. It is exceedingly clear that they are key players in promoting a free-market ideology in healthcare, and whisper endlessly in the ears of our glorious leaders, telling them of the wonders of the free-market. and how it will make everything bright and shiny and new (somehow, or another). One might suggest, perish the very thought, that they might have a conflict of interest in this area. By the way, I don’t think of those who blindly promote the superiority of competition and the free market as having an ideology. I think of them as belonging to a cult – as per the Cargo Cults. ‘A cargo cult is a kind of Melanesian millenarian movement encompassing a diverse range of practices and occurring in the wake of contact with the commercial networks of colonizing societies. The name derives from the apparent belief that various ritualistic acts will lead to a bestowing of material wealth (“cargo”).’

          In this case, the ritualistic act is privatisation – which can work in many settings – but not well in healthcare (see under USA)

          P.S. I have nothing against McKinsey consultants per se. I view them as natural born wolves, programmed to eat the sheep. It is not their fault, it is just the way they’re made. But if you want to keep a few sheep alive, build a fence, or buy a gun.

    2. MGB (@__mgb)

      We must be careful not to feel too vindicated and let it slide, but what can we do about it?!
      This ConDem government appears hell-bent on privatising everything it can get it’s grubby little hands on regardless of opposition.

      1. Dr. Malcolm Kendrick Post author

        I am afraid that all politicians have the same mind-set. They are convinced that the free market is good, and public sector is bad. Of course the NHS is not perfect, but the answer (in healthcare) is not the free-market. This just lets the wolves into the field with the sheep. End result, fat wolves, no sheep.

    3. Chain Reaction

      “we must be losing money from State services to the private sector at an appalling rate.”

      The really significant aspect of the great money trick is that the profits are generally privatised, while financial liabilities and functional risks are socialised. This aspect isn’t influenced so much by ideology, and socialism is a weak force by comparison, the underlying force stems from aspects and attributes of the design of money we elect to use and yet never question.

    4. Harold

      I also worked in the NHS
      You may be surprised to hear but nursing and medical staff are only a small part of the NHS, there are huge numbers of support staff/other departments.
      They all have one thing in common, they are ALL getting messed about by outside “experts”/ parachuted in to save money. It ALWAYS ends in disaster.
      So this story is not the only one in the NHS.
      If it ain’t broke, don’t fix it is common sense. But common sense is the last thing you get from politicians these days.
      It’s all so their pals can make money out of people’s illness.

  2. dearieme

    “Oh the joys of competitive tendering. In order to get the contract you have to bid so low that you cannot actually provide the service” is proof, if proof were needed, that the guvmint – any guvmint – is too incompetent to put work out to tender. However, it is typically also too incompetent to do the work itself. The obvious conclusion is that usually it should never have taken the task on in the first place.

    1. Dr. Malcolm Kendrick Post author

      Indeed, forget the measles epidemic. We have a stupidly epidemic that has taken over all political parties. Immunization will not do, we need a massive cull. Unfortunately, if you shot Jeremy Hunt through the head you would miss his brain by about three feet.

  3. karlwhitfield

    Another good blog post, thanks Malcolm. Certainly, a core factor driving this insane paperwork-intense, and as you say arse-covering, madness is the ‘law suit society’ – every person in the chain following pre-determined, systematized processes to ensure they all did their job properly, because in medicine, no one can be found to have ever made a mistake, for fear of legal action. It is frustrating, but I understand how it has become the norm. So the key question is, what can we do about it?
    How can we turn back the clock, de-centralize, re-localize, open more clinics, train more doctors, take out processes and put back in real people, run fewer computers and pay more nurses, focus on quality of service, quality of healthcare, quality of life for our population, rather than on profit, efficiency, cutbacks, savings, automation and scoring points in performance rankings. How can we put common sense, personal care and personal responsibility back in the system?

    1. Dr. Malcolm Kendrick Post author

      I think we might start by looking at no-fault compensation. Take out the ‘blame’. If something goes wrong there is no need to prove that someone screwed up – stuff happens, sometimes it is no-one’s fault. If we pushed for the idea that you don’t need to drag people through the courts in order to be compensated for damages seems, to me, a good way to go.

  4. Ian Phillpott

    I agree with the fundamental principles of 111 – I.e. you have one number for emergencies and one number for everything else. Making patients lives simpler in this increasingly complex NHS can only be a good thing.

    However, due to a “do it as cheap as we can” and “we must make sure we can’t be sued” mentality a good idea has been totally fouled up.

    The algorithms used are so risk adverse it is unreal. The info passed on is excessive. There is too much call center + automation and less knowledge + experience. Why? Because the latter costs. Never mind the increased costs of ambulances and OOH GP visits etc, that is further down the chain. That isn’t their problem.

    I would like to hope that over time the call takers and systems being used do gain experience (and some hefty re-coding) and that the balance of hcp vs non-hcp in these call centres are addressed. It has the potential to make lives easier.

    However they HAVE to be willing to spend more, listen to all those people highlighting issues and make real chages.

    Chances of that happening? Hmm…

    1. Dr. Malcolm Kendrick Post author

      Yes, I think the idea of having one number for urgent (non-emergency) care is a good thing too. However, it is what happens behind the number that is the problem. Lowest cost bidder, badly resourced, poorly trained. But, hey, lets go for the survival of the fittest by the means of natural selection…..Um, doesn’t that mean that all the weakest members of a species are killed to allows those most well adapted to the environment to breed and pass on their genes? Why, yes it does. But if you deem profit to the purpose of health care provision there will inevitably be certain…um….costs.

  5. Andrea

    Oh my! Much like our 8-1-1 line. We end up with frantic people in ER who have been told to come by ambulance after calling in. They are offended when experienced nurses complete an assessment and send them to minor treatment as they are only mildly ill. Such an annoying way to use resources!

    1. Dr. Malcolm Kendrick Post author

      Amazing, is it now, how experienced and highly trained people do a better job. I think the expression that best sums this up is ‘cheap no good, good no cheap.’ But if you are privatising the NHS the bosses of Virgin etc. need to see a big end of year bonus for them, so they want to see every function made as cheap as possible.

  6. Sister Di

    As a bank nurse for GP OOHin East Cheshire, I could not agree more with your views, as all the local highly experienced triage nurses were given the push! After the system crashed we were asked to take the service back for 6-8 weeks while it was sorted out, especially over Easter etc. Thankfully, we have a conscience regarding patient care and all turned out to help. I despair of health care managers being able to improve the service without a huge cost to the NHS.
    If it ain’t broke , don’t try to fix it !

    1. Dr. Malcolm Kendrick Post author

      Absolutely. The problem is that if dedicated staff keep providing a safety net for underfunded, profit driven, private providers their true disastrous impact will not come to light.

  7. Jacqui Harris

    I am an ex-employee of the 111 service, a health advisor, handling the calls. it should be remembered that all the negative press means staff are the subject to constant verbal abuse, threats of legal action, violence, obscene language and criticism from callers. A tough job with 10 hour shifts, talking constantly, wearing a headset and staring at a computer screen. Training is in-depth including life support training and means all health advisors are able to recognise life-threatening situations. constant on-going audits and assessments ensure quality of care. The call handlers are committed,caring individuals who want the best for all the patients. They did not invent the NHS pathways system, nor did they decide the amount of paperwork it generates. give them a break. Personally, I couldn’t hack it.

    1. Dr. Malcolm Kendrick Post author

      thanks for your comment. Individuals find themselves caught in blunt systems. I would only take issue with your comment that health advisers are able to recognise life-threatening situations. I am sure they may be able to recognise a few of the clear cut things. However, my issues lie with those at a different level.

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