Never Mind the Bollocks: 10 Things Emergency Medicine Consultants Can Do Now to Help the NHS Stay the Best Healthcare system in the World

Scotland has a serious politics hangover, and now the party conferences have started up in earnest. The NHS is front and centre as usual, wheeled out like a beat up old Jag that mostly still goes like a dream, but has had some very unfortunate internal modifications over the years, and is currently towing a caravan full of improvement specialists. It needs some expensive work done, but the garage report says its well worth saving and is definitely much better value than using rental cars.

We know that politicians mostly talk bollocks about the NHS, influenced by which lobby group or vested interest has their ear at the time. We in Emergency Medicine on the other hand can have some real influence on whether we stay at the top of the healthcare global charts in spite of them. Here's my 10 point check for us EM consultants to do our bit, divided into DCC and SPA activities.

On the Floor: Speed, Safety, Cost-effectiveness

1.     Make clear disposition decisions based on risk, and only admit patients who really need it. Think: “If not me, then who better to be gatekeeper?”

2.     Use robust evidence-based guidelines combined with experience to assess risks and standardise treatments in the right context. Science and art of medicine.

3.     Ensure important time-critical things happen quickly. Early resuscitation, sepsis care, pain-relief, revascularisation and haemorrhage control improve quality, outcomes, patient experience and length of stay.

4.     Consider early DNR and end-of-life care when treatment futile and simply prolonging inevitable death. What would we want for ourselves?

5.     Avoid confusion and duplication by clear communications with in-patient team, GP and patient/family. What needs to happen next and by whom?

In the Meeting Rooms: Focus, Clarity, Candour

1.    Say at the start of every meeting; “This meeting will have been a success if we achieve what outcome?” If no clear answer given, leave and go do something useful for patient care instead.

2.    Do not tolerate the cruelty, danger and inefficiency of ED overcrowding. Make everyone’s life hell until they fix it - the more senior the better.

3.    Talk up the importance of EM senior cover at every opportunity, and plan how to stretch cover across as much of the day as possible. We are the answer, now what was the question?

4.    Take every opportunity to analyse, critique and evaluate EM service performance. Seek to improve every small pixel that makes up the picture. No one looks good with their head up their own ass.

5.     Teach, support and inspire trainees, med students, ambulance staff and nursing colleagues to understand the key role of EM in turning chaos into order. We are the NHS.

Our Wee Bit Hill and Glen

After the flag waving and songs, the bluster of economic pseudoscience, the bogus arguments about cultural differences, the dirty tricks of the financial establishment, and the genuine angst of people reluctantly empowered, we will on Friday 19^th September 2014 still have emergency departments in Scotland to run. And with either outcome, there may be trouble ahead in our NHS.

   If we wake up in the world’s newest nation state, we will surely enter a period of intense turmoil and uncertainty. It is very difficult to imagine that this will not lead to some damaging caution in health spending, at least until the financial industry takes stock and reboots itself. Of course, if the pessimists are right and the economy collapses, health funding might remain constrained for a very long time. Doctors may themselves begin to consider relocating to other areas of the world to avoid the turmoil and the distinct possibility of higher taxes. This drain of talent may continue indefinitely, as it is highly likely that the accreditation of specialists will continue to be recognised on either side of the border (such as now occurs between Australia and New Zealand), thus allowing easy economic migration in search of better wages and/or conditions in England.

  If alternatively, we wake to the confirmation of remaining in the UK, we have the distinct prospect of taking a hit in public spending following proposed

austerity-focused cuts in the rest of the UK through the Barnett Formula. Furthermore, the enactment of the TTIP could force the Scottish devolved NHS to open itself to overseas private competition, thus driving a parallel destructive orgy of privatisation to that of England. This scenario ends with a US style market driven health service that provides expensive, defensive mediocrity and gross inequity of provision. The loss of Scotland carrying the beacon for the retention of the NHS in its original and highly successful form, may also then consign the whole egalitarian principle to history; a casualty of the voracious appetite of global capital to make quick money without conscience.

   In either scenario, I worry about the grassroots effect of this political frenzy on running our departments, particularly in the urgent need to continue to fund improvement and recruit and retain excellent staff. Furthermore, I worry about the distraction from the very real world current problems of roster vacancies and overcrowding that are damaging patients and the reputation of our healthcare system.

   So, as a plea to both camps: come Friday morning, Scotland will have come through a major crossroads. As the dust settles, we still need to receive adequate continuity of funding to provide a level of healthcare as befitting this wealthy nation we are told we live in, whoever will be in charge. But also, perhaps given that health is an already devolved issue, and the government will continue to have tax raising powers whatever, how about taking advantage of all the talk from both sides about social justice and the importance and value of the NHS? Simply immediately put forward measures to increase top rate income tax by 1p in pound, remove the discretionary points system for consultants and use the resultant income to fund the expansion in rest home care places, chronic disease programmes, hospice care and 24/7 acute services necessary to banish overcrowding, bed blocking and boarding.

  It would be nice to have something concrete to show from what may be prove to be a very brief window of political engagement to improve the way we run things on our particular piece of ground.

Competition, Co-operation and the W*nker Theory.

The pervading wisdom is that public health services, designed on co-operative interaction, need to be exposed to “market realities” by introducing competitive forces to make them more efficient. In fact, we already have this tension of ideas on the trading floor of the emergency department.

If the ED tone is too friendly, accommodating and conflict-averse, patients risk being stacking up, denied access to any specialty guarded by a territorial, overstressed or inflexible registrar. Such patients may then end up in poor old Gen Med for days longer than necessary, awaiting the specialty input it was obvious they required from the start, or worse, inappropriately discharged and coming to harm. However, if the ED tone is too stroppy, hectoring and directive, patients risk being hurriedly bundled into pressurised specialty beds causing stress, animosity and unseen down stream pressures for that service - not least the admitting registrar being castigated on the post take round for being “too soft”. Indeed, such is the nature of the balance between collegiality and high-handed siege mentality for the duty ED consultant, that if during the course of a busy shift in the emergency department there is not at least one annoying w*nker from the in-patient services to patiently manage, the annoying w*nker might indeed be yourself.

Emergency registrar slain for absent CRP

The whole referral game can sometimes deteriorate into competitive set pieces, in which move and counter move is anticipated and blocked. ED docs playing the game with experience and seniority roll out their moves with skill and confidence, playing key bits of information like ace cards to force the opposing player to fold early. Juniors, new to the arena, apologise and squirm as the weary specialist dances round their rambling referral like a matador, weakening it with a series of well practised weary requests for irrelevant absent information. More tests and the gathering of multiple other opinions are suggested.  It is intimated that the referrer has lost either their faculties or their bollocks, and thus any ability to make a reasonable decision. The overall quality of referrals of this nature from the ED in general is questioned. Finally the killer blow of “no beds anyway” may finally finish off the sorry spectacle, and leave the referrer thinking twice before re-entering that arena for the rest of the shift.

Of course, most of the time those on shift in the hospital realise they are working to a common purpose and co-operate together seamlessly and good-naturedly to the patient’s benefit.  But if referral were always dead easy for the ED, would we fall into the trap of not earning our corn as a specialty ourselves? Emergency Medicine’s greatest contributions to health outcomes and economics are generally the early input of time-sensitive treatments to minimise morbidity and mortality (e.g. antibiotics in sepsis), and the safe discharge of patients who do not require in-patient care (e.g. PERC negative patients with pleuritic pain). Once an ED referral is accepted by an admitting team though, the EM doc is relieved of the responsibility of finessing the diagnosis and the worry of discharging the patient home. This creates a very strong temptation to glibly, even sloppily, “buff and turf”. This behaviour becomes closer and closer to routine operating practice when the department is overrun with new patients, overcrowded due to access block or staffed by inexperienced or burnt-out docs. Such practice may then undermine the value the specialty adds to those most important of health indicators: outcomes and costs.

Chilean Mine Rescue: no w*nkers

It may just be possible however, to have a highly functioning referral system that utilises both co-operation and competition to produce great results. How? Give the ED direct admitting rights to all specialties, selecting the most cost-effective and safe disposition for their patient using evidence-based practice, senior supervision on the floor and clear pre-agreed referral points (e.g. pre or post CT for stroke). Then simultaneously exploit the competitive egos of the ED consultants by presenting them with detailed performance feedback benchmarked against colleagues from both within and outside their department. Furnish them with a list of not only admission percentages, did not waits, critical incident and lengths of ED stay on their watch, but also collated in-patient mortality, length of stay, and regular feedback from all specialties on patients they admit.

Arguably human behaviour is equally influenced by the desire to co-operate and the urge to compete. Facilitating co-operation and trust on the shop floor, but yet encouraging healthy competition for excellence between senior practitioners may tap into this very effectively. Then nobody has to be a w*nker at work.