Broken.

Is healthcare fundamentally broken ?

Is the NHS about to collapse ?

The companion piece to my earlier post about the state of nursing today : https://dirtywetdog.co.uk/2021/12/24/who-would-be/

My answer to that post by the way is ‘not me’ and not because i wouldn’t want to do the job but that i wouldn’t have the basic qualifications ( A levels) to get onto a university based nursing degree course. Sometime i must tell this story in it’s full version but in brief that just before i left my last main career job i happened to see the job specifications and qualifications required by the nurse who would take on my job…..a job that i was a part of creating…..anyway, the essential requirement was a degree and ideally a masters degree, so technically i wasn’t even qualified to do the job that i’d created and being doing for several years !.

Having seen acute hospital based healthcare from ‘the trenches’ as it were for the last 40 years – last September being the 40th anniversary of my own entry to a school of nursing, i’m now seeing the NHS from the opposite side : not as a patient ‘client’ or even ‘customer’ but as the partner of a nurse whose elderly parent looks less and less likely to survive his latest bout of decline. Also this year i saw it from a different angle again when i visited my own elderly parent in a nursing home shortly before her own death.

In this post i want to outline what i see as some of the problems of what i think i see as a ‘broken’ system – my former life tends to make me see it through the lens of nursing but also in the latter years of my own healthcare career is worked closely with doctors , from the most junior right up to the senior consultants so to some extent i saw and lived with their experiences too.

As of January 2022 there is likely to be a major crisis in healthcare staffing, especially in nursing , and that is mainly down to the fact that nearly all nurses will be exposed to the Covid virus, many will do home tests and discover that they are positive as a result of which most of them will have to self isolate and stay off work. Add to that that there is some small amount of absenteeism and a large amount of sickness from other causes, low morale and plain exhaustion then there could soon be not enough ‘bums on seats’ to staff the hospitals ; what happens then, when the staffing rosta shows no trained nurses for a ward for a shift god only knows.

Maybe it won’t happen that way although i suspect it just might , given the way this government has acted so far……basically nonsensical rules upon rules…..i wonder how they will act when told that hospitals have simply run out of staff…..what then ?. I for one am fully expecting to be ’rounded up’ somehow with a ‘requirement’, supported by a compliant press and an ignorant public that it is my moral duty to go back to a hospital job especially as i am still , on paper at least, still a registered nurse.

Anyway, less of that for now – allow me instead to start to sift through some of the debris of a broken NHS and specifically the sharp end of acute hospital care.

The picture below isn’t of an ambulance station – rather it is of ambulances queued up outside of a hospital’s A&E department while the crews wait to transfer their patients and can’t because both that department and the rest of the hospital are already beyond capacity.

I could start with some raw statistics – how many admissions were waiting to be seen in the local A&E , how long the expected waiting time to be seen, how long some patients spend on trolleys in A&E corridors waiting for a hospital bed……i could even give similar numbers for how few staff there are actually on duty ; the problem being that mere numbers don’t tell the story unless you have the mind of an accountant…..or NHS manager for that matter.

Instead i’d like to start with the story of a single patient from the time that the GP has seen the patient, decided that he needs hospital care and has made the referral and the call to the ambulance service.

Down here in the south west UK ambulance response times are slower than most of the country because Devon and particularly Cornwall are large counties with small roads and many patients live in remote rural locations , even where we live anything immediately life threatening really needs an air ambulance if one is available – i can tell when one comes to the village because their flight path is straight over the cottage and onto the field just across the road. In this case though the call is classed as a low priority call and because many of the area’s ambulances are already queued up outside the nearest A&E it is several hours before one is tasked with the pick up. I have heard anecdotal reports of patients waiting at home with actually happening heart attacks for more than 8 hours ; in the trade we used to say that ‘time is muscle’ meaning that the longer the delay of treatment the more heart muscle dies and the worse the eventual outcome.

In this case the elderly patient is picked up just a couple of hours after the referral and arrives outside the A&E just half an hour later but where it then waits in a queue for 2 hours before even beginning to take the patient inside but even then the patient and crew wait for 7 hours in the corridor before being transferred to a hospital trolley to be seen and assessed which itself doesn’t happen for another hour or so……when finally assessed and the decision to admit is taken it is now 27 hours from first referral to landing in a hospital bed. Just as an aside – the ambulance crew can end up spending their entire shift waiting with their patient in an emergency department corridor and that means that that vehicle and crew are now unavailable for anything else…..a major call or life threatening incident perhaps.

So, why does that happen ?

In most acute hospitals across the country the emergency department is the front door where patients are first seen, some medical/surgical decisions are made and some treatment is initiated but what the system relies on is usually an acute medical admissions ward/s which then take the patients and start to treat their problems while waiting for a ward bed that is more specific to their problems ; thus cardiology, respiratory medicine diabetes management and so on although it’s crucial to add that most elderly patients today now usually present with multiple problems (co-morbidities) .

One thing that we have to say about that is that nearly all patients undergo more tests, treatments and procedures than they ever did in the past and that more of them will receive treatments at a greater age than was ever the case in the past . A small example of that is that both of my grandparents died (relatively young)in the 1970’s of quite simple conditions which were regarded as untreatable then but are routine problems and treatments today……to be briefly specific, bowel cancer and COPD ; today, both of them would have been treated even to the extent of a stay in intensive care which was largely unknown in the 1970’s.

The way i would have expressed that as a senior specialist nurse was that we treat a larger population of more elderly patients with more chronic health problems and we apply many more tests and procedures to them including surgery and many more medicines than we ever did before. The simple outcome of the above is that acute hospitals try to admit and treat more patients than they ever did before but under the conditions of less beds, less staff and far worse support/discharge services.

As a longer term observation, maybe even a radical one, i would say that acute hospital care is broken because long term health i the human population is now broken and has become ‘brokener’ since the 1960’s and i would suggest that the numbers tell us that that phenomenon is tightly correlated with with the change to a high carbohydrate and calorie dense diet : many of the chronic diseases of the modern world can be traced back to that change in human diet which was brought about by politics, industry and medicine itself. It’s as though we (medicine and healthcare) created the problem with a bit of help from the ‘food’ industry, pushed along by American politics/policies and a hugely ‘helpful’ pharmaceutical industry.

Fifty years ago most people lived out their natural lifespan and then died – both of my maternal grandparents became ill and died within a few days : today, many/most elderly people live in a state of miserable ill health and decline for years, even decades as their chronically worsening state of health is ‘managed’ with more and more medicine and increasing bouts of hospitalizations to slap on another band-aid temporarily……..and so the misery goes on.

Right now we are on the verge of a genuine new crisis in healthcare and a situation in acute hospitals that has never happened before – it’s possible , i may be wrong, but that large chunks of the acute healthcare sector are about to break down completely. It will take some time to explain how, why and what – to give it due attention it’ll have to be a separate post.

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