Why isn’t the NHS performing well enough out of hours?

Having spent more time in hospitals over the last few weeks than me or my family would have liked, I was very struck by Seth Godins latest great blog post http://sethgodin.typepad.com/seths_blog/2012/04/the-end-of-the-diva-paradox.html , talking about the ‘death of the diva paradox’.

My dad’s recent ‘simple’ hip replacement wasn’t quite so simple so I got to see the workings of an NHS General Hospital up close and personal over three weekends.

The nursing team on the ward were great – the polar opposite of some of the recent stories about hospital experiences. A nursing and ancillary team working together giving genuine care.

The picture with Doctors was mixed. It took most of one Saturday for a doctor to even ring the ward and authorise a procedure (which the nurse carried out) and most of the next for someone to actually come and see my Dad. All the time this was happening my Dad got sicker and his condition deteritoated in front of our eyes. His expected 3-5 day stay was actually 3 weeks.

Is this a people problem or a system problem? I guess a bit of both. However you cut it it seems wrong that the hospital was providing a 9-5 / Monday – Friday comprehensive Doctor service and a skeleton staff for the rest of the time. How many other businesses would run at 25% utilisation rate? So I think system design is wrong. The Police service learnt this lesson years ago. As a PC I knew that often the most senior officer on duty at night was a single Inspector for the county. Now system has changed and they have Chief Inspectors and Superintendents – recognising that some things need experienced decision-makers on the ground. They may not be experts in a particular field but they can coach more junior people and are more likely to be able to get something done when other experts are needed.

But why is the NHS system so inefficient – is it a people problem? Is this because some senior doctors are acting, in Seth Godin’s words, like ‘Divas’ and NHS management can’t shift them to new work patterns? A harsh assessment? – probably, but somehow there needs to be a recognition that people in hospitals are sick 24/7 and it is unacceptable to leave the vulnerable just sitting there whilst nurses endlessly page the handful of overworked junior doctors on duty and don’t get a response. Inexperienced people make slower, and less effective decisions. In these situations experience counts. That experience needs to be available at the bedside (even if it is delivered via smartphone video conference)

Couple of ideas spring to mind. Should there be a couple of consultants on duty in the hospital all of the time? Even if they are not specialists in a particular field they can offer a steadying hand for the less experienced doctors, and are also more likely to be able to judge when the right moment is to wake up Mr Blogs for a consult.

I wonder what would happen if each hospital published its “time taken for a doctor to respond to their pager” metric alongside mortality, etc. It would be a great proxy metric for “does the system work out of hours” which lets face it, is the thing you should worry about for 75% of your stay in hospital.

The transparent act of publishing this measure would inevitably lead to focus on this area. This might not be wholly the right prescription but something needs to happen, because I have seen a lot of good people in the NHS being thwarted by a poor system that is wasteful and dangerous, and it is almost certainly happening in a hospital near you right now.

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About iansthoughts

Chief Operating Officer at DEFRA, and former council Chief Executive. All views expressed are my own and not formal policy of my employers current or past.
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