A&E departments and the M25 effect

I’ve just done a shorImaget slot on the local radio, talking about the ‘crisis in A&E’. It was based on the new report by the Health Select Committee that highlights the issues, but says very little that is new about their solution. We know that A&E is the ‘safety valve’ for the system, we know that the patients are confused about its role, and we know that fewer and fewer doctors choose to work there.

However, the solutions mentioned by the Committee are almost entirely structural and unimaginative: beefing up the Urgent Care Boards from small talking shops into larger talking shops really isn’t the answer; neither is a vague exhortation that Ambulance Trusts should become ‘care providers in their own right’.

Perhaps it would be helpful to reframe the issues, and consider them in a slightly different way. If we look at A&E from the perspectives of hospitals providers, of those working in the community, and of patients themselves, we might get a more rounded view of the problems and maybe their solutions.

Hospitals are under tremendous pressure; they have to see patients referred to them within eighteen weeks, admit acutely ill patients from Casualty in under four hours, and do it all within ever tighter financial and quality constraints. To deal with the front door issues posed by A&E, they have introduced more and more services there, so that for many patients, turning up at the emergency department offers a ‘one stop shop’ solution to their problems. The paradox is that the more that is provided at A&E, the more the service will be used.

Clearly, the corollary of reducing services at the front door is probably not a viable option in political or practical terms, but at least we should be aware of the dynamics of supply and demand in this setting, and think twice before we get seduced by more manifestations of the M25 effect.

From a community services perspective, it’s worth asking what the incentives and disincentives are to sending people to A&E: in the middle of the night, at an ill patient’s bedside, when relatives are panicking, no other care facilities are available, and the hospital light is on (to use Stephen Dorrell’s image), why shouldn’t the ‘on call’ clinician send the patient into hospital?

The presence in NHS111 of a telehealth service that seems to do no more than signpost the road to A&E doesn’t really help either; one of the reasons we have trained professionals is to cope with risk and uncertainty in a way that an algorithmic system simply cannot do, and offering a cut price alternative was predicted by everyone but the party politicians not to work.

From the poor benighted patients’ point of view, they are faced with the emotive issues of ill health, with little or no information, often on their own, fed by a media diet of Holby City on the telly, and instant gratification in all other aspects of their lives; they also know that if they call their GP they will have a battle to be seen promptly, and if they ring NHS 111, they will probably be told to go to A&E; so once again, what’s the disincentive for them?

Complex issues cannot usually be solved with simplistic sticking plasters, so whatever single concrete suggestions are made will not be enough; indeed, given our track record, playing around with the system (any system) in a ‘quick fix’ sort of way often compounds the problems, and puts different parts of the system under strain.

However, applying a deliberately opaque and undefined solution, whilst harder to quantify and assess, does allow the system (and particularly individual professionals within the system) to use such a solution constructively and effectively, and to feel more involved in that solution; ownership is a recurring theme in all the current manipulations of the public sector.

Thus, giving Acute Trusts a new process measure to meet, such as a new Trolley time target would merely stimulate a new ‘gaming’ solution (what is the real purpose of medical assessment units, for example, if not to take the strain off the A&E four hour target?).  However, contracting with the CCGs for an outcome measure of reduced admissions (and giving them control of the resources currently involved) would allow them to be inventive and innovative in their approach, involving their own professionals, and letting them see the direct benefit to patients, to hospitals, and yes, to their bank balances too.

The GPs who are involved in running CCGs aren’t bad at understanding health and illness, and the ways in which patients are involved (or not) in their care; they are also infinitely practical and pragmatic, so if given the tools to create a solution to a problem with which they empathized, then we might begin to see some progress.

Without their ‘buy in’, no single prescription can ever work, even for Bruce Keogh and Stephen Dorrell.


This piece is based on one first published in Pulse Managazine on 24 July 2013, entitled ‘Another sticking plaster for the A&E compound fracture’

Referrals by numbers: consultant league tables

table - June1What are the criteria you apply when you refer a patient for a surgical opinion and possible operation? How much of your decision is based on evidence, and how much on ‘gut feeling’?

The likelihood is that, as an informed professional, you base your consultant referral decisions on judgments that include a bit of both: some quantifiable data (e.g. waiting times, lengths of stay, readmission rates etc) with a number of ‘softer’ measures about the consultants concerned (such as how nice they are to patients, whether you get on with them, your kids go to the same school, and so on) and about the patients being referred (will they get on with the surgeon, how far will the relatives need to drive to visit, whom do patients actually want to see, and suchlike).

What you are unlikely to do is base your decision on any one of these factors on their own; the social skills of a doctor are important in diagnosing and treating patients effectively, but are not enough to predict good results. Similarly, any single technical measure is too reductive to be of much use; it is too linear in the same way that the price of a computer is too linear. In the case of the latter, I need to know more about the size, computing power, display, operating system, and software (to mention but five factors) before I can make any kind of informed decision.

Thus, I would suggest that new ‘league tables’ such as the National Vascular Registry are just as unhelpful on their own, because missing out on most of those other markers of complexity makes them impossible to interpret on their own: their bald figures give little if any sense of context. If Prof X in London has a higher mortality rate in his surgery than Miss Y in Leeds, is that because he is a worse surgeon, takes on more risky patients, works with less able junior doctors, or has recently had a messy divorce? Is she a better surgeon, or does she only do a few simpler procedures that are intrinsically less dangerous? On their own, the figures don’t tell us any of this.

And even if the figures do reflect the quality of the surgery itself, it is worth remembering that surgical statistics, like all statistics, deal in probabilities, not in certainties; using Miss Y’s figures tells us what happened in the past, but her future results can only be inferred from them. For that reason, one needs to challenge how much weight to give them against issues such as distance of treatment from home, hospital ‘hotel’ facilities, and other extrinsic factors that may influence the whole patient experience, to say nothing of the intrinsic factors such as age, gender, social situation and co-morbidities.

As professionals who spend their whole working careers dealing in ‘soft’ variables like these, GPs are better placed than most to make the appropriate interpretations; patients, whose experience is limited to events in their individual lives, and perhaps those of a few family and friends, are less well prepared. That being the case, how useful is it to publish such information in the public domain, politically incorrect as it may be to suggest such a thing? Publishing the surgeons’ ratings in the Daily Mail is probably the least desirable outcome of all.

In other areas of consumption where consumers are not experts, there are often guides produced to help them make more informed choices; thus for example, the Consumer Association will list the criteria they use in assessing the quality of any particular product, and even make explicit the weightings they give each one; they will (to mixed effect, it has to be said) try to contextualise their findings, so that any reasonably bright but uninformed reader can gain a more ‘three dimensional’ view of the product, and make reasonable, logical, and effective choices. Alternatively, shoppers can follow the ‘Apple Store’ route and go to a reputable shop, where the assistants are trained to offer advice and informed guidance to the customers (although this is usually biased towards making a sale….).

Whatever the ‘purchase’, the messages are the same; in areas of complexity, simplistic measures are not helpful, and may indeed be perverse. Expert knowledge is required, which may be learned by the dedicated consumer, or offered by a guide, that may be written, or embodied in a good sales rep, or an objective, informed ‘care manager’. In health terms, that person is (or should be) the GP, with a good working knowledge of the medicine, the local NHS Trusts and their consultants, and an ongoing understanding of patients’ context and needs (preferably both physical and social/psychological). It is the GPs who should be the main customers for the ratings, not the red top daily papers.

This piece is based on one published in Pulse Magazine on 17 July 2013

CCG: friend or foe?

Friend or foe1Put yourself for a moment into the shoes of a GP; not an ambitious, management focused, media hungry go-getter, but a doctor who wants the best for his/her patients. Your list size is average, which means that around 1600 patients are registered with you, and depend on you to co-ordinate their care, and be their first point of contact, their main provider of care.

Do you happen to know how much the NHS spends on an average GP list each year? Using the back of an envelope (so the figures are approximate), I worked out that  in 2012, the UK NHS budget was close to £110 billion, which was available to look after about 60 million people; that works out at about £1800 for each person, which meant that for an average list, about £2.9 million was available. Scary isn’t it?

Now obviously, quite a lot of this was spent on fixed overheads like Public Health England, and redundancy packages for displaced managers, but let’s ignore these for the moment, because it’s always been the Government and ‘The Centre’ that have determined these. The important point is that since April this year, control of over two thirds of this budget has been handed over to CCGs, to spend on commissioning services for their patients.

The logic underpinning this move has been explicit since the 1990s: GPs co-ordinate their patients’ care, and their referral of these patients determines much of the activity in the community, mental health and acute sectors; so who better than these individuals to ‘own’ the resources associated with all this activity, and use their knowledge, common sense and autonomous professionalism to begin to move activity in ways that improve both the effectiveness and the efficiency of that care?

All the reforms of the past two decades or more have been moving towards this end. GP fundholding, GP commissioning, PCGs, PCTs, and now CCGs, all have been designed to wrest control of activity as much from politicians as from the large provider organisations, to stop them peddling their vested interests to the public (often through the tabloid media).

The logic of all the policies developed over this time (Working for Patients; ‘a primary care led NHS’, ‘the New NHS-modern, dependable’; Equity and Excellence: Liberating the NHS; to list but a few of the buzz phrases) have all been pushing in the same direction, albeit with different structures in place to make the policies happen.

So how does this link to the title of this piece? Are CCGs a Good Thing for GPs, or a Terrible Disaster? I started by pointing out that in theory, GPs each have the power to control the manner in which £2 million pounds or more should be spent on the care of their patients, so I’ll follow that up with two challenges.  The first is: who do you think better understands patient flows and needs: patients’ GPs, or middle managers based in whatever incarnation of health authority happens to be in vogue? Only GPs know what their patients’ medical needs really are and with the freedom to be innovative, they could probably think of all sorts of ways of doing things better, more quickly, in more user-friendly ways: it’s £2 million pounds, for goodness sake…

But my contrary second challenge is about strategy: £2 million may seem like  a lot to you and me, but it’s only a couple of trees in the enormous woods of the NHS; how do we a) maximise its impact and b) minimise the risks to individual GPs, their practices, and their patients? The strength of general practice lies in individual patient care.  If GPs are to be involved in planning and procuring services for entire lists, then they will need ways of working that offer economy of scale and provide insurance against unexpected events (imagine what a cluster of motorway crashes over a holiday weekend would do to the Trauma & Orthopaedics budget) without destroying the ‘can do’ spirit that has been so integral to their success over the past 65 years.

Where CCGs are genuinely ‘owned’ by their GPs, then the new organisations have great potential.  As in any successful corporate entity, individuals will need to accept that the needs of the group will sometimes trump their own local issues, and they will have to toe the corporate line a lot more often than they may have done in the past. However, they should then expect their CCG ‘corporation’ to offer support and act on practical suggestions often enough to show the practices overall benefit and maintain their loyalty. They could then be seen as ‘friends with teeth’, where the relationship needs constant effort and development, but where the gain (whether in terms of patient care, professional satisfaction, or even primary care development) justifies the pain.

However, if CCGs are either run in a top down fashion, or driven by political rather than care based priorities, then it will not take long for the cynicism to emerge; like the PCTs before them, such CCGs will quickly be seen as foe, whose actions are to be resisted and subverted.

In summary then, CCGs have the potential to be THE agent for change in the new world of NHS England, but only if their growth and development are carefully nurtured. The large scale leadership developments that seem to be emerging from the new Leadership Academy have never worked before, so it is hard to see how they will be more likely to succeed this time. What is needed is enough interest to be engendered amongst ‘working’ GPs to persuade them to invest some of their precious time and emotional energy in getting their show on the road, and make it a show of which they, and the entire NHS, can be proud.

And that won’t happen without effort or resources; but with the potential for every GP with an average list to really influence how £2 million is spent on his or her patients, isn’t that investment worth it?

This piece is based on an article first published in Pulse magazine on 24 June 2013