February 1st, 2016

Another piece for The Guardian website – part of a month of (anonymous) articles from different contributors, illustrating the reality of life on the front line of the NHS.

You can read the article here.


November 30th, 2015

This was something I wrote for The Guardian website / Healthcare Network. It looks at the cost of litigation in the NHS, and how it might be impacting on frontline services, particularly with the Rapid Response Team.

Helen is lying on the sofa. She’s only just got up and she’s still a little tousled in her PJs, but despite all that, she’s as bright and poised as any of the paintings or ceramics that surround her.
‘Thank you so much for coming,’ she says. ‘I’m sorry to be a pain.’
Helen is sixty-two, still in full-time work, Yoga classes, trips abroad, perfectly independent. This has been a bad week, though. Her sciatica has flared up and put her out of commission again. She was worried there might be something more sinister going on, so she went to her doctor. He referred her on to us, the Community Rapid Response Service.
‘Physiotherapy sorted me out last time,’ she says, folding her arms. ‘I expect that’s what I need now.’
I agree with her, but say that every new patient we see has to go through an initial assessment and basic health screen first. As an Assistant Practitioner with the CRRS, it’s my job to conduct the screen, to take her blood pressure, temperature, blood sugar, SATS and pulse, dip her urine, assess her risk of pressure area damage, her nutritional state and so on (ECG and bloods if necessary) – in fact, all the basic observations necessary to form a picture of where her health is at the moment and what she might need. I’m sorry to have to bother her with it all. I tell her I’ll do my best to shimmy through the paperwork as quickly as I can.
‘But it’s my back,’ she says. ‘Couldn’t I just see a physio? Don’t you have them on your team?’
‘We do.’
I hand her a leaflet; she reads it while I work.

The Community Rapid Response Service was devolved from existing Community health services five years ago, aimed at reducing inappropriate admissions to hospital. An acute, three day service, it’s made up of occupational and physiotherapists, nurses, assistant practitioners, care assistants – all the front-line staff needed to help keep a patient at home. We have pharmacists to review medications, mental health nurses and social workers, and access to equipment providers for everything a patient might need. The majority of our patients are elderly. They suffer from a variety of problems, but their situation can often be characterised quite neatly with yet another health service acronym: NCH (Not Coping at Home). We take referrals from GPs, ambulance crews, community health workers and the hospital, and after three days the patient will either be discharged from us to a community bed, longer-term care provider, or to live independently again. Unfortunately, that three-day limit can extend indefinitely, depending on availability. A few of our patients have been on the books for months. We do our best to move things along – there are consequences for delays – but sometimes there’s nothing we can do, and the same names come around at morning handover.
Increasingly we find mixed in with the deserving cases some that are as bewildering as Helen. A fit company director of fifty-two, finding it difficult to get upstairs with a temporary knee brace. A seventy year old with full mental capacity, living independently with some family support, but who doesn’t want to take her type 2 diabetic medication. A fifty-four year old alcoholic with a sprained ankle. But whatever we think of the referral, each one will get a full assessment and health screen, a case discussion and the formulation of a plan. When they’re discharged, they’ll need processing by the admin team, and filing.
Everyone on the team wants each patient to get the best possible care, and I don’t doubt that’s true of clinicians higher up the chain, but sometimes I think that a fear of litigation is the real driver behind some of these referrals.

Litigation is a serious problem. According to the NHS Litigation Authority, the NHS in England paid out over £1.1bn in 2014/15 to lawyers and patients, with the figure set to rise to £1.4bn in the coming year. Alongside operating costs for the NHSLA of £2.6bn (actually an underspend of £1.4bn on the predicted figure), the problem is severe and getting worse. An attempt to curb disproportionately large legal bills may dampen things down, but year on year the upward trend is set to continue.

Not quite so easily represented on a graph, but still of equal significance, are all the ‘below the line’ costs that thrive in the febrile atmosphere of risk aversion. The paperwork that mutates into bureaucratic form-filling, less to do with clinical communication and more to do with insulating the practitioner from the chill of the court room; the referrals that degenerate into an NHS version of ‘pass the parcel’, (where the aim is not to be left holding the patient when the music stops). Like any other service operating in Primary Care, the CRRS does its best to navigate these pressures, struggling to maintain a workaday buffer between GP surgeries, the ambulance service and A&E departments. But when the workload is increased with inappropriate referrals and pointless form-filling, deserving cases are at risk of a more dilute service. Ironically, I would argue that a culture of risk aversion means mistakes are more not less likely to be made.

Back at the hospital in the offices of the Rapid Response Team I hand over my patients to the Co-ordinator.
‘I didn’t understand this one,’ I say, moving on to Helen. ‘A fit sixty-two year old with a recurrence of sciatic back pain. The doctor’s obviously not worried it’s anything worse and she’s not stuck flat on her back. Her obs are fine. She just needs some physio. I don’t know why the GP referred her.’
He shrugs.
‘The GP pays in to the IPCT. They’re entitled to use us.’
‘How is that cost effective?’
He laughs.
‘No one gets sued,’ he says. ‘Everyone’s happy. Except the lawyers.’
‘So now what?’
He starts typing.
‘We send one of our physios in. She gives her some exercises. And if she thinks she needs it, she’ll get a referral to Short Term Services and their physios.’
‘Another referral?’
He stop typing and sighs.
‘All right,’ he says. ‘Moving on. Who else have you got?’