Saturday, November 2, 2013

Game-changer II : Redefining specialism?

So how bold are we willing to be? We talk about integration..a much vaunted and noble intention which perishes at the foot of tariff, multiple providers and the financial bottom line. But at least the discussions are ongoing...love it or hate it, you can't deny one thing, the restructuring of the NHS has brought to light some serious debate about roles, patient care...was everything ok before all this happened? Ask Francis, ask Berwick, ask Keogh...the changes have been long time forthcoming. You can disagree with the principles of no holds barred competition but the focus to give patients a voice, have safety high up on the agenda, challenging GPs and Consultants..nothing wrong with that, nothing at all. Anyone who feels these are non issues and had no need to be tackled...one suggestion..don't let your political belief or ideology blur the need for some long over due debate about patient care in the NHS.

So in the Game-changer series, lets discuss acute Trusts first. Are we ready to seriously discuss the role of an acute hospital? It's an acute care hospital, so lets think about where all specialities should sit. 

I will give you an analogy..in a crack football team, you have the divas, the high profile show ponies but without whom you won't actually win anything. So you look after them well and make sure they perform for the team. In NHS speak, would that be your interventional cardiologists, orthopaedic surgeons? Stop mucking around...look after them well and make them the jewels in the crown..make sure they only go and moonlight for another team when they have fulfilled their commitment to the team that pays for their salary.

Next comes the defence...the unsung heroes, the ones who actually deliver the game, each mistake highlighted...in NHS speak would that be the Acute Physicians, the ED folks? Again, recognise them for the hard work they put in, the long unsociable hours and make them feel wanted. 
The next thing a good team needs? Some good midfield generals...some folks who can run the show..make sure the attack and defence are connected, marshal the troops...in NHS speak, they are called Medical Managers. Train them properly, not just someone who puts their hand up, select those leaders and recognise their roles. Any successful team needs a fantastic back room staff...that would be the managers, HR, non allied health professionals. 
And the rest? You either have them on the sub bench or think whether they need to be in the team or not. Did you say a good team needed a good manager? That's the Executive team..who if good have the skills to make a good team a world beater.
Have a think...what's the purpose of an acute hospital? Its to deliver safe, efficient, kind and empathic care to someone who is acutely ill...isn't it?

So can acute Trusts have that boldness in them to open the discussion where some specialities should sit? Can we have a debate where chronic disease specialists should be? Why not in the community with acute trusts buying from them services that genuinely needs to be in an acute hospital? Would our GP colleagues develop a federated model and have LTC teams sit with them? A seamless organisation- integration not in name but in reality. Or even with community providers..a community based pathology needs to be based in the community- not in an acute Trust...that's what the refrain is- so are we bold enough to flip that model on its head? Or are acute Trusts bold enough to own the whole system and have an acute hub and a chronic disease hub?

Think of a future where bar a few genuinely acute specialities, everything sits in the community with acute trusts using services from this community hub as the patient needs. You want a mixture of specialties available as and when especially with patients living longer and with multiple morbidities...well...here you go...no perverse "referral costs me money, so lets plod on". 
The thing that stops this is the survival of hospitals and the perverse irony is that they will possibly survive as an acute care centre if departmental budgets, job plans are all thrown into the mix and CCGs are bold enough to look at that future. Without that as long as the system have made Trusts slave to the financial margins and tariff, then they have no opportunity to innovate and we keep trying to force multiple providers march to the same beat..but in a game of competition, someone will lose as regards finances...and who wants to lose when the repercussions are so high?

So what about the unscheduled care or flow of the patient through hospital you say?....well..more on that next week..but for now...ponder that one....forget all the politics and money for a second...but where SHOULD your specialty sit..not for your convenience but what would be the right thing for the patient lost in the maze of multiple providers? In your heart..you know the answer. 

Till the next week where we throw some ideas regards an acute patients journey in a hospital...before we think what could be done with Clinical Excellence Awards...no harm in dreaming, right? :-)

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