In the new jigsaw which is rapidly becoming the 21st century NHS, a whole range of issues culminate in one operational headache, the inexorable rise in demand, which is being felt across the system. From primary care, through to ambulance and community providers and into the emergency department, the growth in unscheduled activity seems to be relentless.
Ambulance trusts will say that last winter’s natural surge started in February, but never went back to normal levels. Hospitals will say that, whatever front end triage they use to deflect patients away from admission, it is ineffective because the additional patients seen are ill and need inpatient care.
Elective care is a casualty because bed occupancy is high and discharge is difficult when community care packages seem to be less available than previously. The loss of income as a result can put a trust’s viability into question because of the marginal tariff paid for unscheduled care.
It is tempting to circle the wagons, point at another organisation and say it is all their fault.
I’ve heard this recently. “Primary care needs reform” say the ambulance and hospital trusts. “Don’t look at us” say primary care, “we’re flat out already and out-of-hours services are the problem or the reductions in social care.” It’s easy but not productive. And it’s absolutely understandable when everyone wants to do the best for patients, keep quality high and still hit their bottom line.
One thing is clear. This one is not going to go away.
We (the Ambulance Service Network), recently held a workshop on clinical turnaround, the process by which ambulances arriving at emergency departments pass over care of their patients to hospital staff. The standard for this is 15 minutes. Sometimes, for a variety of reasons, it can take two hours. It’s poor patient care, not just for the patient waiting, but also the patients not being seen in the community or at the roadside because the ambulance can’t transfer the person already being cared for.
Our workshop was attended by GPs, hospitals, commissioners and ambulance trusts. Issues were aired and (for a very short time), people sharpened up their pointing fingers. However, it rapidly became clear that everyone had sections of the problem they could control but no one could solve this alone.
Collaboration broke out.
The need to look across the whole of the system was recognised and the conversation switched to how this could be approached. Who would play the convenor role beloved of the old strategic health authorities (SHAs)? What was the magic painkiller that would take away their biggest headache?
I don’t mean to sound flippant or disparaging. This has the potential to destabilise the whole of a local system or indeed the national one. Only a system-wide approach to it will enable better mapping of where the current services have gaps or overlaps which are confusing, unhelpful or downright bad for patients.
It needs commissioners (old and new) to be in the room with providers and local council services to invest wisely and promptly in response. It needs information systems that can track individuals through all of their interactions with health and care using a unique personal identifier. It needs leadership and a clear understanding that the public access services in ways that make sense to them, based on what they know, read or have been told.
It might not make logical sense to the service, but no amount of exhortation will change it without changing their experience. Their motivations are just as important as our processes if we are to control the rise in demand we are seeing.
In short, if there was ever an issue for collaboration ,integration and joint planning and commissioning, this is it. If there was ever an opportunity to prove or otherwise that the reformed NHS ,with its deeper clinical involvement and broader public service links, can transform and improve how people are supported by health and care, this is also it. And if there was ever a problem that needed that new partnership with communities and the public to work, well, you guessed it.