The last few months have seen me spending considerable amounts of time in hospital. Not, you understand, in a bid to catch the marbles spilling out of my ears. No, whatever ailments I may have are a mere side-salad to Old Mother Allardyce’s veritable feast – one that has had her pinging in and out of A&E as if attached to its doors by elastic. It’s a sorry state of affairs, brought on by her existing conditions and age, for sure. Also, by the impact of the hospital’s managerial ethos on its modi operandi – which is why I’m writing about it in a blog purportedly concerned with education policy. For, while Mother Allardyce snored through the long nights spent waiting for a bed, and while my better half and I sat beside her gurney, bug-eyed and nuts with sleep deprivation, I had the oddest sense of déjà vu…
Ma Allardyce is frail enough these days to have been admitted to hospital, several times, with bouts of violent vomiting. Most of these have ended with her being rehydrated and sent on her way – except for the occasion on which she was rehydrated, warmed up and sent away, having been blue-lit into the resuscitation unit with an accompanying temperature drop well below what’s considered hypothermic. Unsurprisingly, she was back five days later, with exactly the same, dangerous symptoms. In hospital parlance, this is known as a “failed discharge” – a term hastily retracted and divested of its paper trails, when those who’d uttered the words realised that Allardyce eyes were narrowing at their implications.
The reason for our repeated visits is that, once sepsis has been ruled out, no attempt has been made to investigate other physiological causes of the vomiting, the hypothermia or, indeed, the fact that my mother has lost 13% of her body weight in six months (a 5% loss over a 6-12 month period is considered a ‘red flag’ symptom). The hypothermia was deemed “environmental” by someone who, never having been to her house, was able to declare, with confidence, that it was too cold. Let the record show that the heating is turned up to levels that make a 10-second walk along a corridor feel like an hour of Bikram yoga.
Those of us with experience of working in schools know that, while Every Child Matters, Some Children Matter More Than Others: those on the Grade 4/5 threshold, for instance, at whom every resource is lobbed, in repeated bids to drive them over the line. Meanwhile, woe betide those unable or unlikely to clear the same, for whom off-rolling awaits. So it is – or something like it – with the elderly and their medical care, starting with reduced checks for certain (potentially fatal) illnesses, and ending with geriatrics being discharged at speed, only to die days later from undetected infections.
That’s also what happens when an institution’s right to survive is determined by imposed targets: other matters become un-targets, as do the people to whom they’re attached. Sepsis is, clearly, the issue of the moment, over which – and not unreasonably – hospitals are held accountable. There’s a formidable list of checks in place, to determine its possible presence and set the wheels of treatment in motion. However, should it not be the root cause of a patient’s ailments, the diagnosis seems to be “Bu99ered if we know.” Ad infinitum. Or nauseum, at least.
I’ve seen this before, in a different form, having worked in the NHS when the Quality and Outcomes Framework was introduced. QOF gave GPs financial incentives to maintain checks on patients with particular conditions. The choice of ailments was not nonsensical, being those that threatened serious – sometimes, multiple – consequences, if left unattended. And so, reception and admin staff spent much of each day working through lists of patients with said conditions, to ensure that appointments securing incentive payments were made.
One unfortunate, if unintended, result was that other patients found the phone lines even more engaged than usual – a particular problem for those too immobile to visit in person. Another was that serious conditions not on the incentivised list were often sidelined. This is why practice staff were instructed to regard as low priority a diabetic patient, whose legs wept with arterial ulcers that refused to heal – a condition that, by clinical standards, warranted attention. (In this case, the patient was treated, in camera after hours, by a doctor and practice nurse opposed to QOF’s introduction – not an option available to all in similar predicaments.)
The second reason our hospital experiences felt familiar is their underlying economic imperatives. Or, as Mother Allardyce would describe it, the state of being “penny-wise and pound-foolish”. Confirming a diagnosis costs money, as does any follow-up treatment it entails. Still, how much of the NHS’s valuable resources are spent – wasted, even – on repeat admissions that, with a bit of investigation, may be avoidable? I assume and hope that any savings made by current practice are reinvested somewhere vital. Otherwise, there’s little to show for the patient’s ordeal.
Perhaps to distract attention from the accidental admission of failure, two young medics became disproportionately excited about a brief spell of diarrhoea Mummardyce had experienced – a typical consequence of the weapons-grade antibiotics she’d been given on her previous admission, just in case the sepsis that wasn’t there was actually there. This was seized upon, so to speak, as evidence that she must have been constipated but no longer was, as proven by the fact that her rectal passage was behaving exactly as it should (huh?). Whatever, a predictable episode of the runs became the favoured talking point, thereby circumlocuting any ignorance of her major symptoms’ causes. Suffice it to say that we now attend a different hospital. And that the Rosetta Stone does not look like an impacted bowel.
Which brings me to the third reason why I felt that I’d been here before (apart from the fact that I had): the most senior member of staff to examine my mother on any of these vomit-spattered occasions was a registrar – the medical equivalent of a teacher with a few years of post-QTS experience. The majority of examinations have been carried out by foundation-stage medics who, like NQTs, have attained the necessary post-nominals, but have yet to complete the period of practice without which they are not deemed qualified. While I don’t know that it’s the fault of other inexperienced staff, I do know that the current crew was working from a set of notes that had recorded a life-threatening cardiac episode three years ago as “hypertension”. That’s quite an elision.
When informed that my mother had been seen by a consultant – an invisible, silent and odourless one, presumably – Mrs Allardyce and I pointed out the error of the claim, at which point it was quickly amended to her notes having been seen by a consultant. So, to be thorough about this, an experienced medic looked at some notes made by a trainee carrying out an unsupervised examination, and based his/her assessment thereon. Is it just me, or is there a parallel with matters about which I’ve been droning on ad infinitum et nauseum?
Piecing together the picture these fragments afford, we appear to have a system that is being forced to rely heavily on cheap staff who also happen to be pretty inexperienced; staff who (are encouraged to?) make target-driven decisions that benefit some at significant cost to others; target-driven decisions that are often designed (though the staff may not always be informed of this) to save or make money; money that could be spent on better-informed processes that could yield longer-lasting results. But that don’t. Because the decisions needed to implement them do not get to be made.
Physician, heal thyself.