Monday, 9 September 2013

Sharing the load

It's amazing what you can learn from a different perspective. My new job has me working in the community, where I sit at the interface between the acute hospitals, and the GPs. Put alongside my role within the organisation, it is a fascinating mix.

The challenges that face healthcare delivery in the future can be hampered by giving too much air time to one's own particular challenges. For example, the pressures being faced by the acute sector can be managed in a number of ways. The solution chosen really depends on where you are viewing the problem from. For example, if you choose to view the issue purely from the operational perspective of the acute hospital, then your solutions will be directed towards capacity, efficiency and crisis management.

If however, a more system-based view is taken, then your solutions may well centre around how the rest of the system can take some of the strain for the acute hospitals.

The reality of healthcare at the moment is that Emergency Departments and acute pathways are under pressure. There are no doubt a host of reasons for this. But we can boil it down. More people go to A&E, where they perhaps present late in their disease process. They are seen by junior doctors, working in departments that are struggling to manage the throughput of patients, often functioning without a full complement of consultants (many departments have struggled to appoint and retain A&E consultants). The fallout is that the decision to admit or refer is influenced by the late presentation of the patient and the need to ensure that clinical risks are not taken. This is understandable. And, I suspect, inevitable. When you place a health system under strain, staff will take actions that reduce the strain on them, but will also try to minimise the risk to patients.

Under different circumstances, things could be different. If the staffing levels were higher, or if the patient numbers were lower, then doctors could take the time to ensure that they have assessed patients as thoroughly as their presentation allows. Take out the pressure of time, and staff have the breathing space to apply their best thinking to the patient. If there were more consultants, then junior doctors would benefit from easy access to expert opinions, and a better training experience.

But can we imagine significant changes in staffing levels, patient numbers, or consultant presence? Of those factors, the issue that seems to be most remediable is patient load: by ramping up the system in other places to take on some of the work currently done by Emergency Departments, we might start to make headway.

The solution to acute sector strain may well therefore reside in the ability of the rest of the system to improve pick up patients earlier in their illness, and closer to home, or to implement successful policies to maintain wellness.

Viewed in this way, the stress on the acute sector should be viewed as a symptom of the illness, not the illness itself.

Our actions to treat the illness must involve some symptom relief, but they must also treat the underlying illness. This involves understanding the mechanism of disease, and understanding what aspects of the process can be modified.

I never meant to make a medical allusion, but it seems to fit. We need Emergency Departments that provide excellent care, and we need nurses and doctors to be happy working there. Without their job satisfaction, maintaining safe and expert level of staffing will always be a challenge.

The whole health sector needs to think about what it can do to help out its ailing colleague. The involvement of the whole health service needs to be committed and meaningful, or we risk running a system with great care in lots of place, except at the front door, where it often matters the most.

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