Healthcare - a long rant
I've been having a think about being a doctor. One thing that really concerns me the utter frustration and loathing that most doctors seem to have of their profession. Most seem to think I am insane for wanting to be a doctor, and all have said if they knew then what they know now they would have never gone into the profession. Unfortunately they can't leave the profession as they feel locked into it and need the money to help raise their families.
This all concerns me. I want to be a doctor because I like the feeling that I make a difference in people's lives, even if it's a small difference or even just bringing a smile to their face for a few minutes. I like caring for people, and I like the challenge of diagnosing and trying to outthink a disease. It's fun. However, I gather from most doctors that while these aspects still remain, they are increasingly frustrated with the bureaucracy imposed upon them which is becoming a major hindrance to patient care and negatively impacting upon their ability to do their job and get the same satisfaction out of it that they once got.
Targets are a big thing in the NHS. The government dictates that all patients in A&E should be seen within 4 hours. The government also dictates that all ambulances to respond to CAT A (immediate life threat level) calls within 8 minutes. It also states that GPs need to tick the right boxes for patient care and quality otherwise they don't get paid. This all seems fair enough on paper. In practice however it's a different story.
To start, let’s have a look at your typical CAT A patient, deemed by a computer, not a human allocator, to be an immediate life threat based on key words that are said in the conversation to the call taker. So: we are sent to a typical CAT A patient. 02:00am, kick out time for the pubs: 20 male, lying on ground, ?unconscious, ?not breathing. Call came in from a bystander who was concerned about the patient, but not concerned enough to stop and see if they were breathing. On paper, they could be genuine, but unfortunately I have learned to be cynical and have yet to be proven wrong in my assumptions. I hope one day that I am. (I would like to note that, cynical or not, all my patients get the highest standard of care I can give them.) So we rush there, risking our lives driving at high speed through the streets, blues and sirens blaring. When we arrive, we find the patient, on the ground, 20 something, stinking of alcohol, not at all unconscious and definitely breathing. In fact he's puking, a lot, everywhere. Unfortunately, he's ingested so much alcohol that he can't stand up and is in no fit state to go home on his own, as he insists he wants to do. So we deem him as drunk and incompetent to make his own decisions and take him to A&E.
On arrival at A&E it's packed with many of his fellow partiers, all in various stages of drunkenness. Unfortunately, there are so many people that the wait time is up to its 4 hour maximum. There are only a certain number of beds in A&E. So, while the drunks get these, and a drip to try and sober them up as fast as possible others, possibly more genuine emergencies, must wait. What then happens when all these drunks are in A&E for more than 4 hours? They get admitted to a temporary ward. This ward is usually a corridor, curtained off, still in A&E, but because it has now been declared an admission ward, A&E has met their government target. But in doing so has increase the patient’s chance of getting infection, and are giving them a substandard level of care, as many times there will be no bed to put a patient in. (The government wants to cut more beds from hospitals as well. Hospitals are already running at over 100% bed occupancy meaning that genuine patients may need to sit in a chair in their cubical until a bed is freed up. Wards are also packed as to save money the government has also closed some wards. So infection risk as risen sharply. They have also cut staff, so the staff that are there are worked off their feet just tying to get the basics done for their patients. )
Now, let's take a non-typical admission to A&E, a genuine emergency of some sort. This patient will usually be seen fairly quickly and stabilized. Ah but what now? Say that took about an hour. The A&E doctor now had 3 hours to order tests, get the test results, and decide to admit the patient or let them go home. It's a lot of pressure on the doctor, particularly when the patient may have other complex medical conditions which also need to be managed. This is part of the fun of being a doctor, balancing treatment with risk to stabilize and hopefully get a patient well enough to manage on their own. (Doctors never cure; they assist the body to heal itself.) If the patient comes close to or goes over this magic 4 hours then they have to be admitted, usually to the temporary admission ward, or to another ward depending on their problem, and that may mean that they are getting admitted unnecessarily to an inappropriate ward (say cardiac patient to an orthopaedic ward, because that is where the bed is) and having their continuity of care interrupted because of this magic 4 hour target. It's stressful for the doctor and the patient.
Lastly GPs: take a simple diagnosis of angina. A classic presentation of chest pain on exercise and a diagnosis can be made on the history. Ah but not anymore. Now, despite however clear cut the presentation is the patient must be referred to a cardiologist, delaying their treatment, until they have an exercise test, and then get the results of that test several weeks later, and then about say 3 months have passed and now they can get their angina medication that the GP should have been able to give them when they first presented with the condition. Government targets at work.
So, what's the solution? Well, I know why they put these targets in place; it's a way for the government to measure how well the health services are doing. But I have seen, and many doctors have said, that these targets are measuring the wrong things and are actually having a direct negative impact upon patient care. Take a cardiac patient who has been admitted to an orthopaedic ward. The nurses there are specialist orthopaedic nurses. They can provide a basic level of nursing care to the patient, but he’s not going to get the specialist cardiac nursing he may need because there isn’t a bed on the cardiac ward. Most doctors I have spoken to state that it's these government targets which are causing the extremely low levels of moral in the health service today.
Well, why not just privatize everything then? Get rid of government interference? Simple: because that would be even worse. The NHS and what it stands for would cease to exist and a lot of poor people in this country would be worse off. I think perhaps the solution is to certainly set a target of some sort, but greater consultation with doctor (something the government refuses to do at the moment) needs to happen so that the doctors can say what would be a reasonable measure of the effectiveness and health of the NHS. The NHS is the most efficient healthcare system in the world, functioning on a third of what European healthcare systems function on. More money and reasonable consultation with staff seems to be what is needed to make this into an even better healthcare system. I believe the model was a good one, but change of the right sort is needed to make the NHS survive.
Will this happen by the time I qualify? Unlikely. So I need to seriously think if the benefits of being a doctor. Will doing the things I love will outweigh the bureaucracy, bullying, and low moral I will experience as a doctor? It's not something I can answer easily and will probably require a lot more thinking. I've got a year now till the next round of applications.
Don't get me wrong, I love the NHS. Without it, Andy would never have been able to see the specialists he's seeing and get the medicines and treatment he is receiving. In the US we would never have been able to afford it and due to his pre-existing conditions and any insurance we would get would never have covered him for it. So in that regards it's made a huge difference to our lives. It's not something that Andy or I are willing to give up on. But with moral so low within the health service something needs to change, otherwise we're going to end up with no doctors or nurses left and eventually no NHS. That is something I would like to avoid at all costs. But is being a doctor and choosing to work in a system that doesn't value me or my opinions worth the cost to keep it afloat? It's a very difficult decision. The NHS does so much good, but it's a shit place to be an employee at the moment.
People’s attitude to healthcare also needs to change. I think it is a human right and something that everyone, even the beggars on the street, should have access to. But it’s also a right that is frequently abused by the people who use it. Drinking in this country needs to be reduced or we need to change how we deal with it. I rather like the suggestion of a blogger paramedic who suggested we set up special wards, if needed in tents outside A&E, where drunken patients could go to sober up. It would leave A&E free to deal with other more serious emergencies. I think this is an excellent suggestion, but it will never happen as the NHS will never have the staff to cover a ward like that. Even if they re-opened the closed wards (which would never be allowed), there would be no staff. It’s a pity that the trusts, particuarly in the north are kept so poor. They can't provide the level of patient care that is needed and as a result staff moral falls even lower.
Right, rant over. Back to PhD and cleaning.
This all concerns me. I want to be a doctor because I like the feeling that I make a difference in people's lives, even if it's a small difference or even just bringing a smile to their face for a few minutes. I like caring for people, and I like the challenge of diagnosing and trying to outthink a disease. It's fun. However, I gather from most doctors that while these aspects still remain, they are increasingly frustrated with the bureaucracy imposed upon them which is becoming a major hindrance to patient care and negatively impacting upon their ability to do their job and get the same satisfaction out of it that they once got.
Targets are a big thing in the NHS. The government dictates that all patients in A&E should be seen within 4 hours. The government also dictates that all ambulances to respond to CAT A (immediate life threat level) calls within 8 minutes. It also states that GPs need to tick the right boxes for patient care and quality otherwise they don't get paid. This all seems fair enough on paper. In practice however it's a different story.
To start, let’s have a look at your typical CAT A patient, deemed by a computer, not a human allocator, to be an immediate life threat based on key words that are said in the conversation to the call taker. So: we are sent to a typical CAT A patient. 02:00am, kick out time for the pubs: 20 male, lying on ground, ?unconscious, ?not breathing. Call came in from a bystander who was concerned about the patient, but not concerned enough to stop and see if they were breathing. On paper, they could be genuine, but unfortunately I have learned to be cynical and have yet to be proven wrong in my assumptions. I hope one day that I am. (I would like to note that, cynical or not, all my patients get the highest standard of care I can give them.) So we rush there, risking our lives driving at high speed through the streets, blues and sirens blaring. When we arrive, we find the patient, on the ground, 20 something, stinking of alcohol, not at all unconscious and definitely breathing. In fact he's puking, a lot, everywhere. Unfortunately, he's ingested so much alcohol that he can't stand up and is in no fit state to go home on his own, as he insists he wants to do. So we deem him as drunk and incompetent to make his own decisions and take him to A&E.
On arrival at A&E it's packed with many of his fellow partiers, all in various stages of drunkenness. Unfortunately, there are so many people that the wait time is up to its 4 hour maximum. There are only a certain number of beds in A&E. So, while the drunks get these, and a drip to try and sober them up as fast as possible others, possibly more genuine emergencies, must wait. What then happens when all these drunks are in A&E for more than 4 hours? They get admitted to a temporary ward. This ward is usually a corridor, curtained off, still in A&E, but because it has now been declared an admission ward, A&E has met their government target. But in doing so has increase the patient’s chance of getting infection, and are giving them a substandard level of care, as many times there will be no bed to put a patient in. (The government wants to cut more beds from hospitals as well. Hospitals are already running at over 100% bed occupancy meaning that genuine patients may need to sit in a chair in their cubical until a bed is freed up. Wards are also packed as to save money the government has also closed some wards. So infection risk as risen sharply. They have also cut staff, so the staff that are there are worked off their feet just tying to get the basics done for their patients. )
Now, let's take a non-typical admission to A&E, a genuine emergency of some sort. This patient will usually be seen fairly quickly and stabilized. Ah but what now? Say that took about an hour. The A&E doctor now had 3 hours to order tests, get the test results, and decide to admit the patient or let them go home. It's a lot of pressure on the doctor, particularly when the patient may have other complex medical conditions which also need to be managed. This is part of the fun of being a doctor, balancing treatment with risk to stabilize and hopefully get a patient well enough to manage on their own. (Doctors never cure; they assist the body to heal itself.) If the patient comes close to or goes over this magic 4 hours then they have to be admitted, usually to the temporary admission ward, or to another ward depending on their problem, and that may mean that they are getting admitted unnecessarily to an inappropriate ward (say cardiac patient to an orthopaedic ward, because that is where the bed is) and having their continuity of care interrupted because of this magic 4 hour target. It's stressful for the doctor and the patient.
Lastly GPs: take a simple diagnosis of angina. A classic presentation of chest pain on exercise and a diagnosis can be made on the history. Ah but not anymore. Now, despite however clear cut the presentation is the patient must be referred to a cardiologist, delaying their treatment, until they have an exercise test, and then get the results of that test several weeks later, and then about say 3 months have passed and now they can get their angina medication that the GP should have been able to give them when they first presented with the condition. Government targets at work.
So, what's the solution? Well, I know why they put these targets in place; it's a way for the government to measure how well the health services are doing. But I have seen, and many doctors have said, that these targets are measuring the wrong things and are actually having a direct negative impact upon patient care. Take a cardiac patient who has been admitted to an orthopaedic ward. The nurses there are specialist orthopaedic nurses. They can provide a basic level of nursing care to the patient, but he’s not going to get the specialist cardiac nursing he may need because there isn’t a bed on the cardiac ward. Most doctors I have spoken to state that it's these government targets which are causing the extremely low levels of moral in the health service today.
Well, why not just privatize everything then? Get rid of government interference? Simple: because that would be even worse. The NHS and what it stands for would cease to exist and a lot of poor people in this country would be worse off. I think perhaps the solution is to certainly set a target of some sort, but greater consultation with doctor (something the government refuses to do at the moment) needs to happen so that the doctors can say what would be a reasonable measure of the effectiveness and health of the NHS. The NHS is the most efficient healthcare system in the world, functioning on a third of what European healthcare systems function on. More money and reasonable consultation with staff seems to be what is needed to make this into an even better healthcare system. I believe the model was a good one, but change of the right sort is needed to make the NHS survive.
Will this happen by the time I qualify? Unlikely. So I need to seriously think if the benefits of being a doctor. Will doing the things I love will outweigh the bureaucracy, bullying, and low moral I will experience as a doctor? It's not something I can answer easily and will probably require a lot more thinking. I've got a year now till the next round of applications.
Don't get me wrong, I love the NHS. Without it, Andy would never have been able to see the specialists he's seeing and get the medicines and treatment he is receiving. In the US we would never have been able to afford it and due to his pre-existing conditions and any insurance we would get would never have covered him for it. So in that regards it's made a huge difference to our lives. It's not something that Andy or I are willing to give up on. But with moral so low within the health service something needs to change, otherwise we're going to end up with no doctors or nurses left and eventually no NHS. That is something I would like to avoid at all costs. But is being a doctor and choosing to work in a system that doesn't value me or my opinions worth the cost to keep it afloat? It's a very difficult decision. The NHS does so much good, but it's a shit place to be an employee at the moment.
People’s attitude to healthcare also needs to change. I think it is a human right and something that everyone, even the beggars on the street, should have access to. But it’s also a right that is frequently abused by the people who use it. Drinking in this country needs to be reduced or we need to change how we deal with it. I rather like the suggestion of a blogger paramedic who suggested we set up special wards, if needed in tents outside A&E, where drunken patients could go to sober up. It would leave A&E free to deal with other more serious emergencies. I think this is an excellent suggestion, but it will never happen as the NHS will never have the staff to cover a ward like that. Even if they re-opened the closed wards (which would never be allowed), there would be no staff. It’s a pity that the trusts, particuarly in the north are kept so poor. They can't provide the level of patient care that is needed and as a result staff moral falls even lower.
Right, rant over. Back to PhD and cleaning.