Friday, 30 August 2013

We never really start from scratch

Next week I start a new job in Dorset. My excitement at the prospect extends beyond the reality of living in a beautiful part of the world, with more space, and the prospect of better primary schools for our daughter. It is more than that, because the job I will be starting seems to hold the promise of really examining what geriatrics can do for a widely dispersed population of frail elderly people.

I have long anguished over the reality of geriatric practice, of admitting patients to hospital when life at home becomes untenable due to social isolation, insufficient care arrangements, and the impossibility of overseeing complex matrices of chronic conditions with anything like the kind of attention required. Much of my time in the acute hospitals of North West London seemed to involve inheriting patients admitted out of hours for the want of proper care in the community, managing their hospital acquired infections, dealing with the pitfalls of iatrogenesis, and trying to return them to a point at which they could be looked after at home. Often that point was below the level of function that they had previously held, but the dynamic of the acute sector is to minimise length of stay.

The pressure on length of stay is not just a financial imperative. It is also underpinned by the understanding that for elderly patients, being in hospital is a risk factor for delirium, infections, and a long list of other possible harmful outcomes. For the physician in the acute hospital, often the best outcome is achieved by getting patients fit enough, quickly enough for them to avoid the risk of harm in their own homes. This can be a difficult message to make sympathetically, and too often patients feel like they are being forced out of hospital. And who can blame them? They expect hospitals to provide them with good care, while they take the time to recover.

We have not yet worked out how to do this. One wonders whether we ever will. But is there another way?

For some time, my frustration at my own practice has been the feeling that while I am looking after patients, I get to know them, and their illnesses well. I learn about what works, how they respond, and what to avoid. I learn about the idiosyncrasies of the person, and their body, that can only come with spending time with them. One can observe the evidence-base carefully, but that never tells you how the individual in front of you will actually respond. Patients often don't want to know the percentages, they want to know what they as an individual can reasonably expect. Sometimes the only way to answer their queries truthfully is to give them, and yourself, the time to see how they respond.

Achieving this kind of insight can be done. It takes time, but not just time during the days they are with you. It also takes an investment of time over the course of their lives, through their wellness as well as their illness. If you only ever see patients when they are sick, then you have no clear idea of what they are like when they are well. This is important, and only partially resolved by the emphasis we place on observer narrative. However the description you get from someone else about what your patient is normally like, it is never as good as the impression you get from seeing that patient back to their best yourself.

The practice of the hospital physician has moved away from the long term care of patients. Commissioning arrangements encourage us to discharge our patients back to their GPs. Consequently, we only ever see our patients again when they become sick enough to be admitted to hospital again.

And this creates a peculiar skew to the view of wellness we get. The patients we see are generally sick, and that view is no longer offset by seeing them well again. I do not know for certain what impact this has on my practice, but at its most basic level, it means that in order for patients to benefit from the input of the hospital physician, they have to get sick. They do not benefit from that expertise when they are well.

This gap in service provision creates for me the sense that our pattern of working is mis-aligned. Can it be right to spend most of your time responding to crises, and not working to stop the crises happening in the first place.

What would your practice look like if you designed it from scratch again? There might be similarities, but there would almost certainly be big differences as well. The way that we work is as much a function of history and circumstances, as it is of clinical need.

What would you change? That is the easy bit of the challenge? The hard bit is figuring out going from where you are to where you want to be.

It is that kind of challenge that I now face in a job which is specifically looking to care for elderly patients closer to home, and trying to avoid their admission to acute hospitals, by being more proactive earlier in their acute illnesses.

There is clearly much for me to learn, but it seems that the most important thing is to understand the set-up of the services I am moving to, listen to the ideas floating round, and most crucially, listen to the patients. My idea of what I think they want, and what they actually want may overlap considerably, but there will almost certainly be areas where it is easy to make the wrong assumptions.

So as I embark on this new challenge, it is with excitement, and also a little nervousness. It seems like a very big deal from where I am sitting.

I will let you know how I get on.

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