NHS spending

[The Dangerous Elk]

If I may I would like to throw this into the discussion.

http://www.bbc.co.uk/news/health-37379464

http://www.telegraph.co.uk/news/2016/09/23/reveale...

http://www.independent.co.uk/life-style/health-and...

[loafer123]

4567231 said:

It is very hard under current rota systems to extend elective work. Those working in a hospital would know: the hospital simply runs on a reduced capacity out of hours.

For example - let's illustrate by saying a district general hospital with 20 wards. Usually each ward has 2 junior doctors covering 9-5 (or 8-4 in surgery), but after hours (5-9pm) there may be 1 doctor covery 4-5 wards, and later after hours (9pm-9am) there may be 2 doctors covering 20 wards with 1 medical registrar covering everyone. Let's say the (elective, because emergency already runs 24 hours) operating theatres now go until 9pm, what happens if there is an emergency? Then it will take vital staff away from covering.

It is not as simple a matter as a factory, where more people can be employed in a flash to operate the machinery or rota'ed to cover more hours. Because we already have not enough doctors / nurses during working hours, there is no way it will be safe getting 2 doctors off during the week to cover weekends. It's simple enough paying consultants to cover weekends, and many already do, but routine 7 day care is unlikely to be implemented in the short-medium term without severe compromises in the rota.

Edited by 4567231 on Saturday 13th January 21:05

The availability of doctors is clearly a major issue, but using those doctors more efficiently is clearly in everyone’s interest.

It is certain that keeping operating theatres empty for 12 hours or more of every day is not an effective use of assets.

Just as important is accelerating the discharge process, so at least less operations are cancelled because there is nowhere for patients to go.

[4567231]

loafer123 said:

The availability of doctors is clearly a major issue, but using those doctors more efficiently is clearly in everyone’s interest.

Oh I can assure you there are used efficiently. Many of them are completely overworked and do not have breaks / time for lunch. At the end of the day they then stay late to finish work.

Under the old contracts, they are simply expected to volunteer. Mechanisms now exist for junior doctors to claim their time back / extra payment - although many do not. It is not just about the time / money, it's about how we can improve the system.

loafer123 said:

It is certain that keeping operating theatres empty for 12 hours or more of every day is not an effective use of assets.

Yes and with enough safe staffing I agree however there is simply not enough around. Plus many post-op patients will need a step-down bed in ICU, and it is also not safe to transfer patients to ICU in the middle of the night.

loafer123 said:

Just as important is accelerating the discharge process, so at least less operations are cancelled because there is nowhere for patients to go.

Guess who does the discharge letters? The junior doctors again. There has to be enough of them to do it (timely) for a start.

[loafer123]

OK.

Let us suppose you are right and that the system is working at maximum efficiency, given the number of available doctors, what can help?

Clearly not money within the existing resources. The doctors are already paid and overworked. Is it to pay to bring in more doctors from overseas? Or something else?

[4567231]

loafer123 said:

OK.

Let us suppose you are right and that the system is working at maximum efficiency, given the number of available doctors, what can help?

Clearly not money within the existing resources. The doctors are already paid and overworked. Is it to pay to bring in more doctors from overseas? Or something else?

As I have explained a few pages above, I am only here to report what is actually happening on the ground.

I do not have any explanation nor any solutions.

What I am saying is even now, covering M-F 9-5 is a problem in many hospitals.

Many times the registrars and the consultants have to do the juniors' work, leading to senior workload not being covered (e.g. if no one is there to do discharge letters, the seniors will have to do it - potentially leaving clinics / paperwork not done).

I do not have any proposed solutions to extending theatre time, because however one does it, it will stretch things further (be it more paperwork, or more complications).

[loafer123]

So if we cannot increase capacity, the only answer must therefore be to reduce demand?

Reduce elective surgery? Reduce the scope of the NHS?

[4567231]

loafer123 said:

So if we cannot increase capacity, the only answer must therefore be to reduce demand?

Reduce elective surgery? Reduce the scope of the NHS?

Maybe, that is not for me to say and certainly political suicide for whichever party who dare suggest this.

All I am saying is that in the last week, I have seen lots (possibly all) wards that I have worked in with corridor patients, nurses responsible for "the corridor", patients shouting down said corridor for attention and no privacy whatsoever. I do not work in surgery but in sunnier times we allow our spare beds to be taken by our surgical colleagues. Now we take their beds.

[Mothersruin]

loafer123 said:

So if we cannot increase capacity, the only answer must therefore be to reduce demand?

Reduce elective surgery? Reduce the scope of the NHS?

Are you applying logic?

[loafer123]

My job is solving complex problems. Mostly that involves logic.

In the case of the NHS, politics means difficult decisions are delayed until after they have to be made, but it will happen eventually.

The answer is therefore;

Increase capacity through more staff or alternative provision to take the heat off existing staff. Operating theatres have spare capacity, beds are blocked, so improve social care provision, build step down beds

And/or;

Reduce demand through limiting what the NHS does and/or making people think twice before seeking unnecessary treatment through some form of charging like France.

[Mothersruin]

loafer123 said:

My job is solving complex problems. Mostly that involves logic.

In the case of the NHS, politics means difficult decisions are delayed until after they have to be made, but it will happen eventually.

The answer is therefore;

Increase capacity through more staff or alternative provision to take the heat off existing staff. Operating theatres have spare capacity, beds are blocked, so improve social care provision, build step down beds

And/or;

Reduce demand through limiting what the NHS does and/or making people think twice before seeking unnecessary treatment through some form of charging like France.

I was being facetious, and completely agree with you. It's logical.

[loafer123]

Ah. Parrot deployed.

[The Dangerous Elk]

DNA stats

http://content.digital.nhs.uk/article/4801/One-in-...

[loafer123]

The Dangerous Elk said:

DNA stats

http://content.digital.nhs.uk/article/4801/One-in-...

It really doesn’t matter.

If easyJet and every hotel you have ever stayed in can manage no-shows, so can the NHS, and they do.

[WatchfulEye]

loafer123 said:

OK.

Let us suppose you are right and that the system is working at maximum efficiency, given the number of available doctors, what can help?

Clearly not money within the existing resources. The doctors are already paid and overworked. Is it to pay to bring in more doctors from overseas? Or something else?

I work in radiology, so some of the efficiency that can be gained in this field is different to what happens elsewhere.

So, there are various options which are starting to come to fruition: radiology is mostly electronic these days, so the data can be sent off site. This means that there is interest in sharing work-load across larger areas (i.e. staff at hospital B can assist hospital A, if they are overloaded; the images and written opinions getting sent electronically where needed). This is increasingly being deployed for out-of-hours services. Instead of having 1 radiologist at each hospital, who might only be getting 1 call per hour. You can have 3 radiologists supporting 12 hospitals, working a more intense but less frequent rota, and with more resilience in case of unplanned absence.

Other strategies are to outsource, where the images are sent to another country, effectively bringing new capacity into the UK. Something which is badly needed, as approximately 25% of posts are vacant. My own site has sufficient work for 2 vacancies, we've just filled 1, but only after 3 rounds of advertising.

The problem is that efficiency savings from shared working, and better IT are reaching their limits - and there is probably only another 10-20% left. We recently audited productivity, and in the last 10 years, a consultant radiologist's productivity has increased by 150% - i.e. a radiologist today does as much work as 2.5 could do 10 years ago - and this is mainly due to technology improvements and more efficient ways of working. But this has only just kept up with the demand for imaging services which has risen at approx 10% yoy. So maybe we can squeeze out the last few drops, but that's only going to buy 12-24 months of demand growth. Then what?

[200Plus Club]

Does anyone ever stop to think about actually maintaining the hospitals if it went 7 day / 24hr? Regardless of the lack of staff in every dept, plant and equipment needed to run theatres eyc needs maintenance. Running it non stop brings that around sooner. They don't build hospitals with "spare" wards and theatres you can decant into.
The NHS also don't get free energy, it's paid for like all companies. Hundreds of Millions of pounds pa additional by going 7 day. Not a penny extra in the budgets to pay for it, never mind staff wages.
Until the NHS is funded inline with growth it's a losing battle.

[JagLover]

loafer123 said:

My job is solving complex problems. Mostly that involves logic.

In the case of the NHS, politics means difficult decisions are delayed until after they have to be made, but it will happen eventually.

The answer is therefore;

Increase capacity through more staff or alternative provision to take the heat off existing staff. Operating theatres have spare capacity, beds are blocked, so improve social care provision, build step down beds

And/or;

Reduce demand through limiting what the NHS does and/or making people think twice before seeking unnecessary treatment through some form of charging like France.

Well the current crises seems to more one in A &E and so it is worth pointing out that the procedures and efficiency of A&E departments varies widely across the country.

The Telegraph had an article about one. From memory all patients are seen by a Nurse on arrival and those who don't actually need A&E are directed to an onsite GP surgery.

They had significantly increased the speed with which patients are seen and it doesn't seem to require limitless funds either.

[V8 Fettler]

JagLover said:

loafer123 said:

My job is solving complex problems. Mostly that involves logic.

In the case of the NHS, politics means difficult decisions are delayed until after they have to be made, but it will happen eventually.

The answer is therefore;

Increase capacity through more staff or alternative provision to take the heat off existing staff. Operating theatres have spare capacity, beds are blocked, so improve social care provision, build step down beds

And/or;

Reduce demand through limiting what the NHS does and/or making people think twice before seeking unnecessary treatment through some form of charging like France.

Well the current crises seems to more one in A &E and so it is worth pointing out that the procedures and efficiency of A&E departments varies widely across the country.

The Telegraph had an article about one. From memory all patients are seen by a Nurse on arrival and those who don't actually need A&E are directed to an onsite GP surgery.

They had significantly increased the speed with which patients are seen and it doesn't seem to require limitless funds either.

In a well-managed organisation, variation would be minimal

[Lynx516]

JagLover said:

Well the current crises seems to more one in A &E and so it is worth pointing out that the procedures and efficiency of A&E departments varies widely across the country.

The Telegraph had an article about one. From memory all patients are seen by a Nurse on arrival and those who don't actually need A&E are directed to an onsite GP surgery.

They had significantly increased the speed with which patients are seen and it doesn't seem to require limitless funds either.

The most efficient system which a few places I have work use is to have the surgical and medical consultants on call doing triage. You want the most experienced person possible doing your triage not you least.

If you read the news you get the appearance that the emergency services are the areas with inefficiencies but in my experience its the elective work where the inefficiencies are.You can't cope with the volume of patients A&Es deal with without developing a pretty efficient system.

That being said it is not an A&E problem. A&E is where the symptom shows. If you have no inpatient beds to move your sick patients out of A&E onto wards A&E backs up. It doesn't matter how fast you see patients if you can't get them out of the department. If you can't get them out of the department and your A&E is now full you have to have patients wait in ambulances.

It also doesn't matter too much how many people turn up to A&E inappropriately (ear ache, etc) as they won't get admitted. Its the volume of truly sick patients who need admission with not enough beds which is the problem.

There will be variation in performance across the system and some of that is in the control of the trusts but a large amount won't. If you don't have any money to build a new hospital/expand you can't increase bed capacity, if your social services are insufficient you can't discharge people and I wouldn't be surprised if better service provision decreases admissions by flagging up problems earlier. None of this is in hospital's control. They are being asked to drink from a hose pipe and are hoping not to drown.

The big problem is that fixing this will probably take a decade at least. Beds have been cut over the last ten to fifteen years as the big push has been to treat patients in the community, which hasn't worked. We also don't have enough doctors or nursers (the latest pay review's evidence says that doctor shortages is a supply problem not a pay problem) and a consultant surgeon takes up to 16 years to train. There is no short term fix for this.

Edited by Lynx516 on Sunday 14th January 08:00

[langtounlad]

[quote=Lynx516
The big problem is that fixing this will probably take a decade at least. Beds have been cut over the last ten to fifteen years as the big push has been to treat patients in the community, which hasn't worked. We also don't have enough doctors or nurses (the latest pay review's evidence says that doctor shortages is a supply problem not a pay problem) and a consultant surgeon takes up to 16 years to train. There is no short term fix for this.

Edited by Lynx516 on Sunday 14th January 08:00

[/quote]

I agree in general and lay the most blame at successive government meddling, underfunding and lack of strategic management.
Political timeframes don't match to health investment cycles (staff and equipment).
The radiology example above is illustrative of the kind of efficiency improvements that should be gained from technology improvements matched to IT and collaborative working across sites.
Too much 'silo' management and failure to invest big and long-term where necessary, and opportunities present themselves, results in stupid outcomes like insufficient staff to operate expensive equipment.

[Brave Fart]

My recent experience of a large hospital where I live is that they cannot move elderly, frail but not critically ill patients out of ward beds. Why? Because the social care isn't there. Such patients don't need to be in a high-tech super hospital, but they can't be sent home or to their care home. They are stopping flow out of A&E and reducing the available bed capacity - not their fault of course!

So, why not build or refurbish a whole bunch of local "cottage hospitals" (for want of a better phrase)? Recruitment can come from anywhere, overseas staff are fine - and when not needed these half way houses could be suspended e.g. in the summer. You pay for it with a x% increase in NI for a fixed term, say ten years. If it doesn't work you turn the cottage hospitals in to care homes which we'll need anyway.

I think some radical ideas are needed. My idea might not work - but what also won't work is the Tories saying "but, but, but we HAVE increased funding!" or Labour saying "we will get The Rich to stump up £40 billion more per year and everything will be fixed."

It's time to think radical, and long term, in my opinion. We can't carry on like we are.