57 Minutes to Save Your Life

57 minutes: The required average length of stay for “major case” patients during peak periods in the new South Glasgow Emergency Department when it is fully operational as one of Europe's largest hospitals by the end of May. More than this and patients will begin to queue for trolley spaces based on current projected numbers. Fifty-seven minutes to make an accurate diagnosis and clinically intervene to maximise the chances of a successful outcome. Fifty-seven minutes to establish a bond with a distressed patient and provide sympathy, understanding and compassion.

Fifteen years ago, when we argued that we needed to close and merge many of Glasgow’s crumbling hospitals to create centralised centres of excellence in state of the art buildings, we made some pretty big promises. There was to be a trade off between losing local access to familiar hospitals and gaining faster more effective, efficient care with sustainable staffing in modern surroundings. Now that the time has come, we need to deliver on those promises.

If we are to make our fifty-seven minutes work, the entire hospital will need to operate like a Formula 1 pit team all the time. Those patients with evidently serious problems such as stroke, major fracture, heart attack, appendicitis, or septicaemia will need to be rapidly sent to appropriate specialist care wards after receiving essential emergency treatment. There will be no time for the traditional multiple repeat assessments in A&E by a hierarchy of junior doctors from the in-patient teams. Patients with more minor problems such as cuts, sprains, skin infections will need to be dealt with in a separate fast-track stream by nurse practitioners or by re-direction to GP services.

For patients with indeterminate symptoms such as collapse, abdominal pain or chest pain, who may or may not have significant illness, blood tests, x-rays or scans will need to be very rapidly available 24/7. By abandoning the old idea of just “admitting for tests” in this large group, we can provide not only more rapid reassurance for many patients but also protect hospital beds for those clearly requiring them. Finally, patients with violent, demanding and disruptive behaviour will need to be rapidly removed by the police if there is no reasonable suspicion of significant illness or injury to prevent interference with the care available to other patients.

Many of these changes are partially underway already, but are often patchy and inconsistent. The 57-minute window will sharply focus the attention of all of us starting work in the new hospital. Some of the changes will involve both a culture shift and spending money. Specialist medical staff from every department, traditionally tribal in loyalty, will need to co-operate with each other as never before for the common good. Managers will need to realise that change of this magnitude cannot be used as a short-term opportunity to look for savings. It will be impossible to achieve the lengths of stay required throughout the hospital without realistic nursing ratios, adequate medical staffing and appropriately matched support services such as physiotherapy, radiography, labs, portering and domestic services. Delayed discharges in the wards awaiting social work placement will need to become nothing more than a regrettable historical blip.

Above all, the entire staff will need to feel proud of their roles in order to maintain a positive attitude through the inevitable challenges. Valid concerns about new working patterns, transport, overcrowding and staff ratios need to be carefully listened to. Recurring problems in these areas will then need to be rapidly addressed by a leadership team who are prepared to make the changes necessary if initially processes do not work and targets are missed. Ultimately, if fifty-seven minutes cannot be made to work we need a Plan B to avoid returning to the misery of overcrowded emergency departments experienced by patients and staff over the last two years.

 The new hospital is an iconic cathedral to 21^st century healthcare and the NHS. The high profile features such as the helipad, single rooms, colour schemes, artwork and use of natural light are great improvements on the tired and decrepit Victorian facilities currently in use. However the new hospital needs to be even more about people working together to make Glasgow a beacon for the world-class quality of care the NHS can provide. Patients should be able to clearly agree that those difficult decisions taken 15 years ago were correct.

When Saturday Comes: Politics, Health and Football

The NHS is political football, whatever David Cameron says. Healthcare policy is realised through relentless, tribal warfare of deep-seated ideologies and the fierce factional loyalties of rival die-hard supporters. Like Rangers v Celtic, Real Madrid v Barcelona, in the Healthcare Championship, there is an historic struggle of ideas and identity going on, but with vested financial and political interests manipulating the conflict in the background. The players on the pitch, the NHS staff, want to put in a shift, score goals and defend well, but the refereeing is inconsistent and frankly a little suspect.

Over recent weeks, many grudge matches have been played out over the UK A&E overcrowding crisis. Every lobby group jumps in to the tackles with their own theory as to the cause. According to them, it is variously the fault of the public for attending with trivial hang-nails, the GPs for not liking being out in the dark or working weekends, the A&E staff for being risk averse and admitting everybody, the closure of local hospitals by cynical politicians, the global financial crisis, the Barnet formula in Scotland, the elderly population, collapse of social care, insufficient district nursing and so on. Every side sets out to secure maximum points and their win bonuses, but no one gets shown a yellow card if the play was unsporting or goals should have been clearly disallowed. Maybe the game could be massively improved if referees looked to reliable data and reproducible evidence rather than the shrill appeals for penalties from the partisan stands or players on the pitch.

In Scotland (using Auditor General data), the numbers of emergency attendances have been going up, but only gradually and slowly (15% in 10 years). On the other hand, the number of elective (planned) admissions has risen rapidly (36%) to meet crowd-pleasing treatment guarantees. The length of stay has dropped in keeping with a degree of modernisation, but this has been way offset by a substantial reduction in bed numbers (7%). The net effect of these changes is increased occupancy, and progressively fewer beds to put emergency patients in. Once a crucial hospital occupancy tipping point is reached, the system collapses because patients are admitted here, there and everywhere, get poorer care and stay longer thus compounding the bed problem exponentially. The Emergency Department then becomes a holding warehouse for new admissions, the staff get burnt out and irritable, and the occasional patient who wanders in with a minor complaint (even though international evidence clearly shows that this group do not ever cause overcrowding) gets the blame for the whole debacle. Losing every week like this has been enough to cause some staff to quit their NHS club and look for an overseas team.

The use of impartial evidence focusing on capacity and occupancy could therefore be the match-winning strategy to resolve the issue of A&E overcrowding. Globally though, the biggest healthcare game is between the self-reliance, competition and market forces of the private sector versus the equity, co-operation and cost-effectiveness of publicly provided services. Here too, use of scores from fairly conducted matches rather than the opinion of pundits may improve the sport for everyone. In a recent properly refereed international play-off, for example, the Commonwealth Fund reported the UK NHS to have been the most cost-effective and equitable healthcare system in the world. Some heavily sponsored teams setting out to take on the NHS may indeed find a level playing field difficult to manage. In fact one such team, Circle United in Cambridge, recently suffered such a humiliating defeat that they voluntarily dropped out of the entire league and are now restricting themselves to playing Rounders.

When Saturday comes, the NHS staff will boot-up and trot onto the pitch. Their long-term performance in the league will crucially depend on their manager, the board of the club but also critically, the backing of the fans.