Thursday, 26 April 2012

Demanding consultant delivered acute care

Who should deal with the most urgent and severe emergencies?

The following runs in every healthcare worker's mind but we usually do nothing about this. Let me describe it.

First time elective referrals at out patients for major conditions gets seen usually by consultants
First time elective major operations usually done by consultants (especially the major ones)

Redo operations after complications due to first time elective surgery - quite often done by registrars or 'middle grades'
First time major emergencies in Resuscitation rooms and dire post operative emergencies in wards and ICUs are usually dealt with by registrars or 'middle grades'

Is that logical? Is that sensible?

Of course in some specialties like vascular, neonatal and a few other, the senior most persons often deal with the most dire things but I am talking about most specialties. For instance in internal medicine an elective referral for a chronic cough or chest pain will normally be seen by a consultant but a severe acid base imbalance, a pneumothorax, undiagnosed sepsis will be first seen often by very junior doctors fresh out of medical school or if the patient was extremely lucky by a registrar or middle grade.

This anomaly should be addressed. But it will not be easy to address. Clinical severity of the condition and clinical severity of any potential adverse outcomes should decide who will see/treat the patient and not mere availability, convenience, historical residual legacies and other administrative/managerial issues. This will demand consultant delivered care (not consultant 'led' care). People will rightly be concerned about the cost; it would be important to recognise that the improvement in clinical quality and the enhanced clinical accountability for outcomes could result in lower overall costs. If on the other hand there was a clear increase in quality the richer economies should accept that as the new benchmark for cost.

Success in Healthcare will depend on the proper utilisation of its very valuable human resource; the utilisation of the human resource should be exclusively based on clinical need - more severe the presenting situation - the more senior should be the primary attending human resource.

Here is where patients could play a part in improving the quality for themselves and in shifting the culture within healthcare. Patients and families could use the consent process to influence better care. Consent is a legal requirement before professionals can provide care hence any caveats in that legal process carries significant weight. Patients and families may or may not be able to define what should be done but they can define what cannot be done; for instance you cannot say you have to be given a blood transfusion but you can say that you should not be given a blood transfusion.  In the same manner I think patients probably cannot demand that only a fully trained healthcare profession should treat them but can possibly decline to accept care from anyone who is not fully trained without them being directly supervised.

For instance my living will or perhaps my consent to treatment form could say 'I, having worked hard and paid my taxes, when I am ill, expect to be treated and cared for at every stage by fully trained clinical staff; if that does not happen I will take it as having possibly received substandard care. Being a responsible citizen and supporter of NHS I am aware of the need for trainees to learn so that future specialists can be created; I will allow trainees to care for me at any time as long as their trainer is physically present and actively training the trainee in a hands-on manner. If the trainer is not physically present and actively involved (for instance if it is a surgical operation the trainer must be scrubbed up and assisting the trainee) I shall consider it as a breach of my right to have received the highest quality of healthcare that I expect and a breach of the consent that I have provided' (** Caution: Using aforesaid statement is likely to negatively affect your healthcare and risk an adverse outcome. The statement is used to make a point and not necessarily for practical use**)

It is patients' choice, let us take it seriously. If you thought this was a bit too assertive - pause for a few seconds and reflect on the day when my above sentences will be cut and pasted by every patient on to their consents and living wills. Or even better, pause and think of what you would want for your child, spouse or parent when they are facing the most dire emergency circumstances of their life perhaps after something that had already gone wrong. Would you want someone who has left medical school recently (though they are very good trainees and keen to learn) or someone for whom you have already paid upwards of £1million to become fully trained and employed to care for you, when you are facing a potentially resolvable life threatening condition? I rest my case.


Wednesday, 11 April 2012

Healthcare not similar to aviation but lessons can still be learnt

Healthcare learning from other industries needs a much higher degree of sophistication

When are you in control and when are your patients in control?

When a plane is flying the passengers are not in control. It is the pilot who is in full control. The pilot also has controls on him/her but that control is not exercised by the passengers. Well, when there are 50 to 500 passengers in the cabin it will obviously be a problem to let individual passengers be in control of the flight itself. The passengers do get some control over their pre-made choices such as seats and meals; the passengers also get some control over when they use the toilets and when they can walk about as long as they are prepared to sit down and belt up as soon as they are instructed to do so. It is actually against the law to disregard pilot or cabin crews instructions; you do not have to harm yourself or others as a result, just not following the pilots orders is an offence.

Healthcare has made big noises about learning from aviation. We can argue that there are some similarities and some differences in the way passengers are treated and patients are treated. Just within the context of this short write up, can a chief exec of a small healthcare organisation or a chief clinician of a large unit say ‘we have a large number of patients to treat and hence we cannot accommodate individual patient choices’? Can clinicians tell patients ‘you have a choice over meals but for the rest of your healthcare you will do as you are told when you are in the hospital’? Will it ever become law that if patients’ disregarded their doctor’s instruction in a hospital they will be prosecuted (for potentially adversely affecting other patients care as a result)? Clinicians 'orders' are not orders at all. Of course it is an entirely different debate on whether the patients will get good results even if they followed their doctor's instructions completely.

The similarities between healthcare and aviation or any other industry for that matter are quite limited. This is for the simple basic reason that healthcare is direct and personal to the recipient – as direct and personal as a professional poking fingers and instruments into various orifices with consent in an attempt to make the lay patient better. That directness and ‘personalness’ does not happen in the often quoted ‘ultra-safe’ industries such as nuclear power plants, scheduled airlines, European railways and so on. It is a totally different empathetic human to human interaction where the 'relationship' is the main driver/lever. The synthetic 'have a nice day' with an artificial smile will not work in healthcare. Its a kind of relationship that a pilot or crew might have when the plane has crash landed and they are trying to rescue frightened and traumatised passengers; not something that they would wish to do everyday and that is something that many in healthcare do every day.

That does not mean healthcare cannot be safer than what it is now. It also does not mean that the ultra-safe industries have nothing to share with clinicians; of course we need to learn more from crew resource management methods, etc. It only means that the lessons and methods can only indirectly be applied; the principles have to be adapted and only then adopted. We are really poor in translating the lessons from other industries into healthcare.

I am very passionate about patient safety and quality enhancement. I have learned a lot from other industries including aviation. Healthcare is a risky business. If we attempt a direct application of the principles from other industries, healthcare will continue to remain a risky business. The translation and transfer has to be much more sophisticated than what it is right now. It is possible.


Sunday, 1 April 2012

No mosquitoes in UK so our healthcare is costly

No Mosquitoes in Great Britain, hence our healthcare is costly

A groin hernia is surgically repaired by placing a synthetic mesh on the weakness and fixing it in place. In UK the mesh currently costs from £20 to more than £100.

This is obviously a significant cost which the rural areas in the developing and poor countries cannot afford. The doctors face an ethical dilemma. Should they refuse to operate since the mesh is unaffordable? Should they do a non-mesh repair which is generally thought to have a many times the recurrence rate of the hernia compared to mesh repair?

Tongaonkar and Reddy, doctors from two small towns in India innovated by cutting mosquito net cloth to shape, sterilised it by autoclave and used it on patients ( They had very good results that compare well with standard international/western results for groin hernia repair. They also had the mosquito net cloth mesh analysed by labs which generally showed it to compare well with commercially manufactured meshes like the ones we use in UK. 

The mesh costs a few pennies; it was 3688 times cheaper than the commercial mesh.

Of course surgeons in India accused the Indian Journal of Surgery of blasphemy for publishing Tongaonkar's paper.

Now here is the good news, a UK surgeon Prof Andrew Kingsnorth uses the mosquito cloth net mesh for hernia repair. The not so good news is that he does not use it in the UK, he uses it in a hernia charity in Ghana which he leads/supports  

One of my friends who has interacted with this blog wrote to Andrew Kingsnorth and the conclusion was that red tape will prevent us from using it in UK. I have discussed this with a number of people, at the very end of the discussion we always wondered why we in UK would not take this up even if we save money. Groin hernia mesh is only a £5million market with already many fingers in the pie. £5 million for the NHS is possibly small change. Our discussions normally end at that point.

We are a developed, rich economy, it may well be that our development and our wealth which prevents us from taking up innovations that save money. You would have never guessed that the lack of mosquitoes in UK was one of the reasons for our healthcare being costly!