Saturday, August 15, 2009

NHS - Putting Patients Last

Is it coincidental that on this Saturday morning, me groggy from last night's responsibility of hosting an "open house" to members of my church, that I should receive an update from Civitas with reviews of their recent publication Putting Patients Last? (See eg this.)

Earlier this week I had phoned two hospitals to try to re-schedule two appointments. I had been given really awkward times during this summer break when I am a full-time carer for my young son.

No, they cannot re-schedule, because it would mess up their six-week targets.

In other words, if I don't accept the appointment given, then we all suffer.

So I had to make some rather complicated childcare arrangements.

Could this policy be a good thing?

Last Thursday I turned up just before my appointed 6.05pm and found that I had gone to the wrong hospital. Yes, I felt like a complete idiot.

This was because I was seen at one hospital and expected the MRI to be done at the same hospital. It didn't occur to me, nor my husband who also read the letter, that the MRI scan was at their "sister" hospital 20 minutes drive away.

As I did not know how I would be feeling after being put into a noisy tube, I opted to take the bus to the hospital. When I discovered that I was at the wrong place I rang the required hospital and they asked if I could get there.

I didn't have a clue. I am well known to be rather directionally-challenged.

Thankfully there was a shuttle service between these two hospitals. One was leaving at 6.30pm and the scanning people told me that if I got there by 6.50pm they would see to me. The staff were also very concerned that I was able to find my way home.

I got there by 6.49pm, thanks to a very sympathetic driver. When they finished with me, I was asked again if I could find my way home. (I had ordered my taxi, thanks.)

NHS staff are really very nice people. Once you got past the appointment making business they are the most competent, most caring professionals. Really.

But I have lost count of the number of times I had been reduced to tears trying to make an appointment on my husband's behalf.

He has a chronic illness and is immuno-suppressed. It is very testing trying to get him an appointment to see the GP to sort out his prescription if he isn't on the verge of collapse. In which case I should be ringing for an ambulance instead.

For those who are unfamiliar, this is how it works for him.

He is under the care of a team of consultants at one of the best, if not THE best, colo-rectal hospitals in the country. But it is the GP who issues his monthly prescriptions, often in response to changes in his regular blood test results.

Sometimes husband suffers a relapse of sorts, or side-effects from the drugs, and he knows his body well enough to know that the prescription should be tweaked. But could he get a GP appointment to advise?

They tell you to ring at 8.30am in the morning for an appointment the same day. I have never been able to get through at this time. It is also, inconveniently, school run time for me. If I needed to see the GP myself, ringing after the school run means no appointments are left.

In reality it is a lottery. You ring at 8.30am and HOPE you may get to be seen on that day.

I tried explaining that husband -- who runs a busy IT department -- cannot expect to stay at home and HOPE to get an appointment.

"I'm sorry. That's the way it works."

I am often tempted to say, "But do you realize that he works to pay the taxes that pay your salary?" Then of course, he could be struck off the list by this surgery for abusing the staff. To that extent, we live at the mercy of the GP surgery's receptionists.

Try booking an appointment with the GP who knows his case? You must be joking.

The wait is usually AT LEAST two weeks. So now I tell him to book at appointment with the GP every time he has a blood test so that when the test results come back in two weeks' time, he has an appointment ready. If he didn't need to see the GP, he could cancel it.

Why do they have such a system?

One reason, I figure, is because patients miss appointments without informing the surgery. Because no payment changes hands, everything seems "free" (it is not, we taxpayers pay), it does not occur to some types of patients that their no-shows mean other patients cannot be seen. How do you correct such ingrained selfish behaviour?

Second reason, targets. Patients have to be seen within 48 hours. So if you stop them from being able to make an appointment other than on the same day, they will be seen withing 24 hours. Target met.

At our surgery you could also phone in the evening after 6.30pm the day before you wish to be seen.

Two problems here. One, I am often cooking the evening meal, trying to get son to bed, etc. Tired. So on both accounts of the 8.30am school run time and the 6.30pm cooking time, my surgery is discriminating against women, housewives, people with caring responsibilities.

Second, if I tried using this system to book for my husband for the end of the day -- so that he could get to work, come back on an earlier train and get to the surgery for the last appointment -- I have to be on the phone pressing "1" for "the next appointment" for about 20 minutes to get to the last appointment.

I don't kid you. I've done that before.

All these just so that targets are met. So is this a case for "putting patients last"?

The truth is, as truth must also be told, we do get very, very good professional care once we get past these gate-keepers of targets aka the receptionists.

During times when the husband had been too ill to get out of bed and I'd rung for a GP to visit, they often come as soon possible to make sure that he was OK.

If one were so ill that one needed emergency treatment, there is A&E. The only difficulty is when you are a conscientious non-acute patient who needs medical advice to make sure that your condition does not deteriorate to the extent that you need A&E, ambulance, etc.

Is this short-termism or what?

Yet millions of pounds are spent every Friday night looking after drunks for free, possibly of people who don't pay much tax at all.

The issue is not just one of putting patients last or first, or somewhere in between. There needs to be a massive re-think on the relationship between a health service and an individual.

These days there is such a divide between the ethos of a universal health service and the notion of being entitled to a universal health service that supply will always not be able to meet the demand.

Take for example the case of fertility treatment. On one hand we do not stop practices that could increase infertility (eg smoking and drinking that could result in cancer, and/or indiscriminate sex that leads to STDs with long-term effects on fertility, etc) and on the other we are spending massive amounts of money helping people get pregnant.

Then there is the anomaly of treating patients who neither qualify for, nor require, a free service.

My friend from Singapore came to see his daughter graduate from university. He fell seriously ill with heart problems and needed hospital treatment and hospital stay. Now he was fully covered by his insurance. Yet when he asked about payment, he was told, "Not to worry. Everything is being taken care of." [update: compare Obama's stepmother's case, see below.]

Why, in this situation, was a foreign non-taxpayer given free treatment? Why was there no attempt to recover the cost of his hospital stay from his insurers?

I have seen TV interviews where medical staff say that it is not their duty to screen foreigners out of the system. If someone needs care, NHS provides it. They are medical professionals. Very good ones, too.

But we hear also of people flying into Heathrow with serious heart trouble or needing an organ transplant, etc. and they, too, are treated for free and we wonder if, along the line, someone has become far too generous (spending our money).

No such thing as a free lunch. Why should I pay for other people who do nothing to contribute to the same system which (presumably) would look after me when I need the service?

And then I keep getting this questionnaire about whether I am happy with the service I get at the GP. Well, I know a thing or two about questionnaire survey design. I have designed several of these in my own professional life.

Guess what? There is not a question about how easy or difficult it is to book an appointment. Lots of questions about whether we are seen to within certain time limits, the decor and comfort of the surgery, the speed with which phone calls are answered, etc, but NOT a single question on my experience of trying to get an appointment at a time that suits my circumstances.

Was it: very easy, easy, OK/average, difficult, very difficult?

The Civitas report suggests that the NHS begins to treat patients as customers. By coincidence I worked on a project for a private hospital in Singapore where they were trying precisely to teach the same: the patient as a customer.

They did not stop there, they wanted all staff to treat other staff members as customers, too.

Not just a digit, not just a hospital or NHS number, not just someone in the system who must be pushed through the relevant numbercrunching gateways with the result "target met".

I live in hope.

For an example of the NHS's creaking bureaucracy, read this post.

Should we have paid for Obama's stepmother's healthcare?

Apparently Daniel Hannan prefers a version of healthcare system akin to that of Singapore.

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