Wednesday, 28 November 2012

Imagine the perfect future, and then ground it in reality

Forgive my absence. Perhaps there is nothing to forgive. But I am back now, and a whole bunch of things have happened: I have secured my first Consultant post, starting in February. I have revelled in the thrills and spills of fatherhood. And I recently got the runners up prize with @tobyhillman in the Finnamore F20 prize, which asked us to discuss what healthcare should look like in 20 years time, and how on earth we make the necessary changes.  

Toby and I thoroughly enjoyed letting our imaginations run, and then trying to work out how we could make the vision a reality. We obviously did OK, but it would appear that one other entry did better, and to them goes my heartiest congratulations. I read their piece - it was a force of reasoning and research, and rather like watching someone else win the London marathon - I was vicariously breathless and thrilled at their achievement.

But from the relatively privileged position of thinking what the future of healthcare should look like, and what we should be aiming for comes the real world challenge of continuing to deliver health care in the current climate.

One thing struck me from my thinking around the subject: I spend much of my time at work helping elderly patients recover from their acute ill health. I spend time getting to know the patients, and how their illnesses respond to treatment. I then discharge them, and have nothing to do with them until they are readmitted to hospital. Perhaps I am over-rating the input I can have in managing patients during periods of relative wellness, but it seems to me that for my input into a patient’s care to be triggered they have to get rather poorly. There seems to be some sense in having the chance to respond sooner and at lower levels of acuity - to cut the major exacerbation or relapse off at the pass.

Current structures of care do not support the kind of collaborative, cross-boundary working that make the kind of delivery of care that I allude to possible. In particular, there is a major chasm in the delivery of healthcare formed by the different contracts that GPs and consultants work under. This might at first glance appear to be a minor issue, but its impact and effect is deep-rooted, and it makes it much more difficult for consultants in particular to work across boundaries.

We also need to have the right kind of care commissioned. We are entering a new world  of commissioning, and I doubt that many people are really that confident how it will all turn out. Just as the PCTs were getting good at commissioning, they are being disbanded, and it is difficult to shake the perception that we are starting again from scratch. The idea that GPs will have a significant role in the commissioning of care has resonance, but it is also a concern. Expert commissioning is not a part time role - it is not something that doctors have trained to do, and it is not something we can expect them to able to just do without considerable training and support.

I was struck by the risk that GP commissioning potentially poses when a GP involved in one of a local CCG told me that I shouldn’t get too comfortable at home on my nights on call as a consultant, because they were planning to commission hospital consultants to be on site 24 hours a day.

Flippantly, I asked him whether he was also commissioning pigs to fly. The point is this: commissioning is not just about writing a wish list of what you would like: the reality of having consultants on site at night means paying for that time, paying for more consultants to cover the work that needs to be done in the daytime, and also makes a statement about the importance of the acute care pathways with respect to the other work that consultants are engaged in.

Acute care is important, but so is the work that we need to do in the future to reduce the demands and use of the acute pathways, by managing chronic conditions better, pre-empting deterioration, and meeting the needs of patients away from the hospital. These work flows will become impossible if your consultant body is either working the night shift, or enjoying the inevitable time off afterwards.

Ask yourself this: if the full time consultant contract is 10 PAs a week, and a night shift is 3 or 4 PAs, where are all the consultants that will be needed to fulfill the rota requirements and the daytime work going to come from?

The way we deliver healthcare needs to change, and it will change considerably. But it needs to be grounded in what is both feasible and desirable.

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