Florence Cunningham trolley.jpg

We know that Sir Bruce Keogh is very keen on ‘wearable apps’ – little apps you can download onto your smartphone to improve your health. NHS England seem enthusiastic about getting senior staff in the NHS to dream up apps to improve patient care. Part of this, presumably, is wishing to make the NHS profitable like Apple; but part of it is genuinely driven by a wish for technology at low or no cost to improve vastly someone’s quality of life.

Apple in their recent launch proudly showed off a new app which could act as a mini research lab, taking samples of your speed of finger tapping for example. It boasted that you could contribute to a giant ‘research lab’, and the multinational corporation showcased people from prestigious American hospitals with impressive titles.

The philosophy behind ‘targets’ in the NHS, latterly being rebranded as ‘ambitions’ in the innocent hope of diffusing their toxicity, was to ensure a minimum level of performance. It is a quick fix way for a politician or hospital manager to say that something is being done. Of course, to total embarrassment of everyone is when targets are regularly missed.

In terms of ‘performance management’, it is hard to see how repeated missing of a target can be good for staff morale. One would think it at first is bad for morale, but, then as repeated missing of the target becomes the new baseline, it can theoretically implant a culture of ‘it cannot get any worse’. This is of course is bad for the organisational culture of any institute, let alone which is supposed to be driven by patient safety. It is this culture, together with a sense of ‘too something to fail’, which presumably kept Mid Staffs and Morecambe Bay in their bad times.

You would not typically dream of rating your experience of a meal in a restaurant by how fast it took you to get your food, unless it was a very protracted way, rather than the quality of the actual meal. You should not wish your food to be rushed to your plate if half of it was blatantly undercooked, and not fit for consumption. You should not be particularly inspired if the restaurant were clearly understaffed, relative to the demand of customers, such that it took you a long time to get a waiter’s attention.

Managers refer to this as the ‘visibility’ of ‘operational management’. A restaurant is a good example, compared to a NHS A&E department, not because of the similarity of the service it provides; but because it is a high visibility service. In other words, it is pretty clear to the ‘end user’ when the organisation of the operation is more chaotic than competent.

In judging how long it takes for an Ambulance crew to arrive at a medical scene, there are clearly unsafe time windows, particularly for acute medical emergencies such as chest pain or anaphylactic shock. But there is a danger if something is then misdiagnosed, sending a patient on completely the wrong care pathway.

What happens at 3 hrs 45 mins of the ‘four hour wait’ target is similarly interesting. A four-hour target in emergency departments was introduced by the Department of Health for National Health Service acute hospitals in England. Setting a target that, by 2004, at least 98% of patients attending an A&E department must be seen, treated, admitted or discharged in under four hours. The target was revised by the Department of Health to 95% in June 2010.

If an A&E team have a few missing results from investigations they’ve ordered in assessing a patient, say a blood test has not even been ordered or the result has not come back from the lab, a clinician (or even potentially a non-clinical flow manager) might take a decision to admit the patient to hospital, or to discharge, to avoid breaking the four hour wait. This decision can therefore be primarily managerial.

A disparity of information between patient and doctor, “information asymmetry”, can mean that it will be clear to the doctor when this 3 hr 45 mins time has been reached (but not clear to the patient). Anyone who has ever been a a patient in A&E, or even worked there, will testify what a stressful working environment it is, taking on a timeless feeling to it.

But a smartapp on your smartphone would be able to tell you this information as you ‘count down’ your experience in A&E. You see, more helpful to you as a patient, and ultimately the NHS, is whether your experience in A&E has been a good one from the perspectives of patient safety and patient experience.

A simple checklist on a questionnaire would be triggered at four hours so that you could ‘rate’ which staff you had seen, whether you had been seen by a senior clinician, whether your investigations had been ordered, whether your test results had arrived, at the four hour mark. If so many people are repeatedly missing the four hour target, there would be plenty of respondents to the survey. You could of course be asked to suggest what you think your working diagnosis might be.

This information could then be downloaded by your GP, the hospital and NHS England, so that they get a feel for your experience in A&E in a way that would be beneficial for rating patient safety and patient experience. Such raw data would be likely to be much more helpful than filling a questionnaire for the ‘Friends and Family Test’ weeks after an event. Such information could be available in real time such that hospitals could be aware if their services in reality were understaffed compared to demand.

The smartphone app might cost the NHS a minimum amount, if it could be downloaded by the NHS patient for 99p. You would not need the NHS to pay vast amounts of money to the types of IT companies you see at Olympia every year at these NHS ‘Expos’.

Such an innovation is clearly disruptive. Disruptive innovation, a term introduced by Prof Clayton Christensen at Harvard, describes “a process by which a product or service takes root initially in simple applications at the bottom of a market and then relentlessly moves up market, eventually displacing established competitors.”

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2 Comments

  1. Gloucester Royal Hospital A& E dept in CRISIS MON 24th feb 2015 FOR THE LISTENING EVENT CQC IN GLOUCESTER 25THfeb 2015

    During the night ( at 3am ) I called for medical help and the paramedics arrived around 3am and after testing , advised that I needed to go with them in the Ambulance to the A&E Dept at Glos Royal Hospital. On arrival at around 3.20am I became aware that a major problem existed at the Hospital as they were overloaded with ambulances with patients needing urgent attention ,so the 2 ambulance staff waited until 4.20 when the ambulance staff passed on their responsibility for me to the A&E staff and transferred me to a Hospital trolley. More Ambulance cases had arrived adding to the overload problem. Meanwhile my trolley stayed in the corridor , in a queue, stretching back to entrance door.

    By around 7. 05 am I left the corridor and I was pushed into Bay 22( Major 2) from which I was finally discharged and at home at around 3 pm . I had spent 12 hours in the A&E dept and tests had confirmed that I had had a mini stroke( A TIA) , affecting my left side.

    . It appeared that available beds were difficult to achieve. I was aware of the degree of stress affecting everyone( staff , patients and family members)during the night.

    After tests were completed , I was offered and accepted that I would receive assistance at home starting to day with the Integrated Community Team , I was pleased to be offerred their support and am at home awaiting their arrival

    I saw a Doctor ( from an Agency)for the first time at 09.10 am- nearly six hours after arriving at the Hospital . His psychological and physical tests appeared to me competent and he wanted and acheived the confirmation of his efforts via a brain scan.

    Other testing by a nurse( temp, blood pressure etc) started around 8am after the night shift had left and day staff arrived- about 5 hours after my arrival.

    Fortunately, I had taken with me some of my necessary medication , tho not all, which I took whilst awaiting attention. On arrival back home 12 hours after my departure, I tried to catch u p on essentials. I had previously learnt that no routine medication can be supplied out of day hours. For people admitted via A& E

    I give permission for my records to be checked about the above story

    This dear Lady is known to me and wants this information put in the public domain. Not to attack the hard working staff who are working in a system that is deliberately designed to fail and that they take the blame for corrupt politicians that are engineering these catastrophes- in order to discredit the finest health system in the world.

    This Lady suffered the same predicament as those in the photo to this article, meaning it is not the odd hospital suffering like this but widespread, the reason we don’t see it on the News every day is obvious, not to protect the hospitals but corrupt politicians.

    People need to wake up to what is happening under their noses, This government has lied to people from the start “there will be no top down re-organisation of the NHS.” Our feeble opposition has allowed them to get away with this, because sadly they have the same agenda and whilst happy to use these situations to beat the Tories with, they will nevertheless carry on regardless where the Tories leave off.

    Critically people need to ask Labour to define what they mean by “commissioning,” Why do we need a “preferred provider,” if they truly are going to save the NHS?

    Why won’t they back the Re-instatement Bill? .

    The Tories said they would ring fence the NHS budget whilst taking out £20 Billion in so called efficiency savings, Neo-Liberal language for cuts. But why have New Labour been so quiet over it and kept it all low key?

    The answer is simple, they will like their predecessors before continue to privatise our NHS.

  2. Cora Blimey says:

    The 4 hr target at A&E is itself a danger to patients. If staff are working to a 4 hr target then the only emergencies that are treated in a timely & safe fashion are those presented through the Ambulance service. This then makes a mockery of the costly 111 service and in fact highlights how obsolete it is and should be. GP services should be the only primary care service outside the hospital provision whether through local GP cooperatives or collaborative out of hours services, which should include minor injuries and walk in centres. They should be the referral system for patients. A&E should be the ’emergency’ service. The current system is ridiculous.

    My story:
    Suffered from recurrent bladder cancer since mid 2012.
    Feb 2015 had most recent biopsy under GA. In recovery area was given some water and blood pressure check & speedily discharged. No measure of bladder efficacy was undertaken, as is usual protocol, so no record that all was well or not & no discharge letter issued.
    I was in some discomfort for a few days but that seemed to pass. I passed no blood so was pleased assuming all had clotted & healed correctly.
    After a week or 2 I again had some discomfort and some discolouration of waste so increased my fluid intake to be safe. It seemed to clear up a little. Couple of days later I passed a tiny blood clot, which is normal as tissue sheds and heals. Had some very low level discomfort so maintained good fluid intake. 2 days later I got up am and passed completely red waste. This included clots. Drank litres of water and rested a little. It started to clear a little next time. The following time it was worse. I phoned my GP and got an emergency appointment. GP prescribed antibiotics and sent off a sample.
    Later in the evening I tried to pee and couldn’t – I drank more. I passed 3 blood clots but no fluid. Drank more. Passed 1 painful large clot but nothing else. At 11pm I phoned 111. I was advised to go straight to A&E as my situation was considered an important emergency and told they would take me straight through.
    At A&E I was booked in and asked to wait. By now I was in 5/10 discomfort level. Triage nurse (working extra hours) saw me after about 15 minutes – took some bloods and said they would get me seen as soon as possible. 10 mins later pain had gone up to 7/10. Husband asked how much longer but told they had no rooms free. Pain became constant & intermitently intense making me cry, shake and swear.
    At this point they asked me to move to the triage side room (was too disruptive for other patients) I couldn’t stand or sit. I could only lean over, bent double and cry and shake. No one observed me. Paramedics, reception, nurses all just looked and moved on. Triage nurse popped back now and then (clearly off badgering people bless her) but she said they still didn’t have a room but soon.
    After 30 mins of arrival the Triage nurse did a bladder scan. She said it showed 900ml but that the ‘machine only measured a max of 900ml and I was way over that’. Then she said they had no one to perform a catheterisation – erm what? They were sending a surgeon down from one of the wards and he would arrive soon.
    The pain was off the scale & I was shaking, breathing, shaking, breathing. My husband was worried I was going into shock and warned the Triage nurse to keep an eye on me and check my blood pressure. This was a very young trainee nurse – competent but out of her depth. She just looked blankly at him.
    An hour & 5/10 minutes after arrival a surgeon arrived and said he wanted me taken up to a ward. Within 30 seconds he knew that was impossible and between him and the Triage nurse they scrabbled around to find catheter tubes, bags and syringes and drained my bladder there. It wasn’t very dignified but that surgeon & triage nurse brought christmas, birthday & easter all in one. I thank them for that. I passed approx 300ml into a cardboard container and a further 700ml into the catheter bag – a furter 100mls soon after.
    I no longer have faith in A&E. It is badly staffed, has the wrong targets and the wrong systems supporting it. Patients deserve better as do the committed and put upon staff who volunteer to work extra hours to keep it open. I remain disgusted at politicians from the main parties, including my own MP. I have now become one of the patients traumatised by our beloved NHS. Strong words I know but I am now petrified of a recurrence and really do not want any more treatment. Feel anxious just from writing this. It is by far the worst experience of my life and I believe actually endangered this life. Had I been older with damage to kidneys or other complications I think this could have been very serious.
    I hope for something better for the future but nothing political I hear convinces me that the NHS will survive and be protected from opportunist & profiteering vested interests.
    The model is already in place in the form of internal market, competition & independant trusts.
    Very sad.

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