The South Wales Programme and Ysbyty Ystrad Fawr

Next Wednesday the South Wales Programme will enter its consultation phase. The engagement phase explained the need to centralise some specialist services - Major A&E, Obstetrician-lead maternity and Paediatric inpatients, currently provided in 7 hospitals in the South Wales area - onto 4 or 5 sites. Three sites located near the three major centres of population in Wales - the University Hospital of Wales in Cardiff, Morriston Hospital in Swansea and the new Specialist and Critical Care Centre in Cwmbran - have been identified as fixed points in the plan. This leaves one or two other hospitals to be selected from the Princess of Wales Hospital in Bridgend, the Royal Glamorgan Hospital in Llantrisant and the Prince Charles Hospital in Merthyr.

The outcome of the process to select the sites will be made public next week, and will identify a preferred hospital configuration to provide these specialist hospital services across South Wales in future. It is important to understand that the process, in which healthcare professionals were closely involved at all times, did not involve any consideration of 'which hospital was best'. It was not a beauty contest. The selection process was designed to identify which configuration worked best in terms of the flow of patients across the region so as to provide the safest, most sustainable and accessible service. Ease of access for disadvantaged communities was taken into account when making this judgement, which involved a wide range of stakeholders, as well as doctors, nurses and therapists.

The Emergency Medicine consultants I worked with as Chair of the Emergency Medicine Clinical Reference Group genuinely believe that reorganising services in this way will improve the quality, safety and sustainability of emergency medical care. It is important to acknowledge that emergency care is in crisis across the whole of the UK at present, but also important to point out that while the effects of this are felt most acutely in Emergency Departments, the changes to correct this have to be made across the whole system of unscheduled care, from the GP service to social care. More effective Emergency Departments with better round-the-clock senior cover are just part of the picture.

Finally, I'd like to talk about the hospitals that don't get selected as centres for the specialist services I mentioned above. It is tempting to talk about these hospitals as being 'downgraded'. Tempting, but wrong. I'm 51 years old now, and entering the stage of my own life where I am more likely to need medical care. I live in Abergavenny, somewhere we already know will have a Local Hospital in future. As I grow older the care I need is much, much more likely to be provided by my local hospital - Nevill Hall. But if I have a serious specialist problem, like a stroke or a heart attack, I would prefer to be taken a little further away from where I live to get the my initial care delivered by the senior specialist on duty round the clock. Local hospitals have a bright future. If you want to know what one might look like, take a look at Ysbyty Ystrad Fawr in Caerphilly https://www.dropbox.com/s/u9j1p3ps0plqx7z/Ysbyty%20Ystrad%20Fawr.doc.

 

Three kinds of emergency care

The identification of healthcare as a business can be problematic. Mainly, I think, because of a sensitivity around the involvement of private firms in the NHS - an issue that has rarely been out of the news in England recently. But I am going to argue that we should think of it as a business, at least some of the time. For two very good reasons. Firstly, there can surely now be no argument that it helps to think of patients as clients we aim to please. Secondly, I'd like to argue that using a business framework helps us to see what we might do about probably the most pressing problem we currently face in healthcare - how to cope with the demand for emergency care. In this area I believe a consensus is starting to emerge on the way forward - that there are broadly three types of emergency care. At the moment all three types tend to pitch up in A&E together. We need to separate them, both conceptually and physically, and get really good at doing each of these three types of emergency care business. At the moment, we're not as good as we need to be.

The first type of emergency care business is honest-to-goodness, drop dead unless it's treated properly, Serious Illness. Heart attacks, Strokes, Meningitis, Punctured Lungs. That sort of thing. Modern medicine is good at this. People who would have died from conditions like this only a few years ago can now be returned to a normal, or near-normal, life in weeks. These are the conditions that encourage people to believe that they need an A&E as close to them as possible. And yet this is wrong. Unless they are unlucky, most people will rarely need this kind of care, and what matters most, provided the department is near enough (which probably means within about 90 minutes travel time), is what is waiting for you when you get there. Running too many emergency units means that senior decision-making is only on tap some of the time. That translates into longer than necessary hospital stays, as well as poorer outcomes. The jury is now returning a verdict on this kind of care - centralising it to fewer locations improves outcomes. And for improves outcomes, read Saves Lives. But it doesn't save money. In fact some investment in infrastructure is likely to be necessary to make it possible. In future only some hospitals, typically serving populations of around half a million people, and with senior specialists on duty around the clock, should do this type of business.

The second type of business is Minor Illness. Minor illness care can, and should, be delivered locally (specially trained nurses do it really well), and is practically limited by demand to anywhere tens of people are likely to turn up every day. But we need to think carefully as a society about how much minor illness care we want to pay for, because when cash is limited there is money to be saved here if we modify our collective behaviour. For instance: if people in urban areas accessed minor illness services at the same rate as their rural cousins we would save millions of pounds every year, just in Wales. And that's not because rural folk are healthier (although some of them might be). They are just more self sufficient. And it might be controversial to suggest it, but how about promoting a bit of personal responsibility in this area? All A&Es are full of drunks every Saturday night. Is that really where we want to see our healthcare pounds spent?

The third kind of emergency care business is arguably the most important of all - care for Older People. Older people have special healthcare needs. Their physiology is fragile. They go off their legs and become confused when challenged by illnesses (typically chest or urinary tract infections) that younger people shrug off. They frequently have several conditions, all of which require monitoring and treatment modification. And they often need social as well as health care. Older people need to avoid hospital where that's possible, and, when it isn't, they need to get out again quickly before they develop 'hospital syndrome'. And yet this is the very group where demand is growing, and where care is currently often delayed, imperfect, and, in the worst circumstances, scandalously poor. Older people were the ones who suffered the most in Stafford Hospital, and older people were the ones who died prematurely. Not because they didn't get high tech interventions, but because they didn't get the simple ones - like rehydration. Sometimes, of course, older people will need to visit a Serious Illness centre. But then they need to get back home, or to their local hospital, as soon as possible. Local hospitals need to get really good at providing care for older people, so they get rapid assessment and multidisciplinary care interventions, and they and their families are fully involved in decisions about their care. And we shouldn't be afraid to say that both families and social care providers have a responsibility to be properly involved in care provision. As with Serious Illness care, there isn't much money to be saved in this area, but not all of the changes we need to make will cost money.

If we are going to solve our emergency care problems, we need to decide quickly how we are going to do business.

Fit for a queen

I have never had a conversation about health with the Queen, although I've talked to people who have. As you might expect from a woman who knows how to fix a broken driveshaft, she is apparently quite comfortable discussing the more robust aspects of the trade. That will have made it easier for John Cunningham to take a history when she was recently admitted to hospital with what sounded like a bout of norovirus.

What was most impressive, however, was the duration of the admission for an 85 year old. 24 hours. The Queen and her medical team seem to have taken the view that it was in her best interests to get in and out of hospital as rapidly as possible. There is a firm evidence base for that. Although the Queen appears to be in good shape for her age, it does not take much to disturb the fragile physiology of an 85 year old. Every day spent in hospital would reduce even her formidable ability to cope. I also imagine that a) the Queen requires little additional in the way of a home care package and that b) if she did it would be fairly easy to arrange.

I am afraid to say that this does not compare well with the care we sometimes provide for 85 year olds in NHS hospitals. On a bad day an older person might wait 24 hours in A&E, and sometimes weeks for someone to fix up a social care package. And the median age of those waiting too long in A&E is now almost precisely 85. Older people have become important clients for all healthcare providers, and we need to get better at looking after them. We need to do this quickly, especially in Wales where our population is ageing more quickly than anywhere else in Europe.

What will excellent services for older people look like? I have been spending a lot of time discussing this with colleagues recently, and some key themes emerge: 1. Better anticipatory care in the community, with more proactive primary care and nursing home liaison; 2. Better recognition and early assessment of older people at the front door of our hospitals; 3. Better management of the movement of older people through hospital; 4. Better 'pull' of older people from hospital by community team in-reach, and 5. Better social care liaison with no unnecessary waits for care out of hospital.

Healthcare providers can do a lot of this themselves by changing the way they work. In some areas we will need help from our social care partners. I feel sure they will want to improve services for older people too. I'm not sure how much of a role liveried footmen will have to play, but I would like to imagine a time in the near future when all our NHS services will be fit for a queen.

Revalidation for Doctors

I thought I should do a short blog about revalidation. Most doctors will now know what this means. For those of you who aren't doctors, it's the process that allows doctors to demonstrate to the General Medical Council that they are up-to-date and fit to practice. From April this year it will be mandatory for all doctors. The basis of this is an annual appraisal where each doctor must produce evidence of:

• Their Continuing Professional Development (all the courses and training they have attended)
• The Quality Improvement activity they have done
• Any significant events they have been involved in
• Multisource feedback from their colleagues
• Multisource feedback from patients they look after
• Any complaints or compliments regarding them

In Wales, doctors will all collect this information on an online database (the MARS system), and will need to show that they have met once a year with a trained appraiser to review this. Any actions they need to take to maintain their skills must be described in a personal development plan.

I have two roles in all of this. Firstly, as a doctor, I have to make sure that all six sorts of evidence are up-to-date for me, and that I have reflected properly on that evidence. A fortnight ago I met with my appraiser to go over all of this, and I'm happy to say that I'm now ready for my revalidation by the Chief Medical Officer at the end of next month. Although it took me a little while to get used to the MARS system, it was easy to use and made it very easy to store my evidence so it could be retrieved quickly and easily in future. It will certainly make preparing for my appraisal much easier, and I have resolved to keep my evidence file updated every month so I don't have to enter everything at the end of the year. Secondly, as the Responsible Officer for the health board, I have to make sure that all doctors have collected their evidence, been appraised, and have a development plan that addresses any issues that have surfaced.

Although it is still early days, the revalidation process feels like it will be a real step forward in assuring the quality of all the doctors who work in the health board. That must be a good thing for patients.

The Francis Report

The publication of the Francis report yesterday was a sobering moment for anyone who works in healthcare. The systematic lack of care described in Stafford Hospital makes gruelling reading. What makes it worse, if we are honest, is that we all know that instances of poor care sometimes take place in our own hospitals, even if they do not reach the epidemic proportions described in the report. How could this happen? Francis identifies a number of causes. Now I have read the report, these seem to me to be three important issues:

Firstly, the danger of focusing on the anything other than the needs of patients. Any director, nurse, doctor, therapist or manager who forgets that, first and foremost, they are there to serve patients is on a slippery slope. And if the board fails to make quality of care its first priority, there can be little surprise if staff become disengaged from organisational priorities. Some people who worked in the Mid Staffordshire Trust lost sight of the needs of its most vulnerable patients, especially older people.

Secondly, we should not tolerate poor standards and risk to patients. It must be right, however much tension it might cause between us from time to time, that we challenge each other to provide a proper standard of care. That is a sign of a healthy organisation. We should also aim for excellence in our care processes. A certain amount of data recording and measurement will always be necessary to make sure we're doing the right things, and we also need to be careful to communicate information properly when we hand over patient care. But we should have a low tolerance for care processes which are wasteful, or cause unnecessary waiting or repetitive collection of the same data.

And thirdly, there is a professional challenge to make sure that we create a positive culture in our healthcare organisation. The challenge to show proper leadership, and followership, is one we must all rise to. We must all make sure that the organisation we work in is open in allowing concerns to be raised freely; transparent in showing how well, or badly, it is doing; and candid in telling people when we have got things wrong.

My first job at Lewisham

The first place I was every paid for working as a doctor was Lewisham Hospital.  On August 1st,1986, I started my medical career as a houseman in general and orthopaedic surgery.   Things were a bit different in those days. We came to work in long white coats, and when one of my colleagues went off sick I spent two months working one in two, something that would be unimaginable for training doctors today (thank goodness). My boss, Lord McColl, had the unusual distinction of having consulted on healthcare systems for both Mrs Thatcher and Colonel Gaddafi.  So I was interested to hear that the casualty department at Lewisham Hospital is now the subject of service reconfiguration. It is clear that people in Lewisham feel the way this has been done, in response to funding difficulties in a neighbouring healthcare trust, is unfair.  But the truth is that one way or another we do need to change the way we deliver healthcare. Apart from anything else, the way we are currently organised does not provide a good service to older people. Too many of them get caught in delays in our emergency departments, and are left waiting unnecessarily in hospital to go home.

Senior managers in the NHS in England are now engaged in a national debate on quality of care and service reconfiguration. There is no doubt that this debate will be sharpened with the publication of the Francis Report this Wednesday. This week's British Medical Journal contains a response to an interview with the head of the new NHS Commissioning Board which was recently published in the Independent newspaper.  Marion McMurdo, the Professor of Ageing and Health in Dundee, wrote in (www.bmj.com/content/346/bmj.f453) with a view that I thought captured the challenge to healthcare providers so well I’ve reproduced it here in full:

“Let's fix our health care system to make it responsive to the needs of the patients who require it. Let's change training and education to ensure that its staff possess the skills to manage people with multimorbidity, including older people. Let's enable prompt diagnosis and invest more in downstream systems designed to allow old people to leave hospital when ready to do so. Let's have equity of access for all patients who require it, and begin the overhaul of the NHS to make it fit for the 21st century.”