Tuesday, 9 January 2018

The NHS needs a whole team – and that has to include administrators

On an afternoon last spring, in the chaos of trying to clear hospital beds for new patients, a frail, elderly man was rushed back to his house the moment that a care package was in place. Behind him, at the opposite end of the hospital, his wife of almost 57 years lay dying. The hospital staff didn’t have the time to be able to let him see her before ferrying him away.

That was my father and that was my mother. She passed away just five days later. I shall never forget the kindness of Winson, a young male nurse who, as I sat beside her bed watching over her breathless body, gently wiped a single tear from my cheek and who, equally gently, encouraged me to remove her earrings – something that I quickly understood was close to the services for our dead that have, so much, been sanitised from the UK’s mainstream culture.

It was the beginning of May. The blossom was falling in the garden that had been her domain. Whatever the reality said, the chaotic state of the National Health Service was not the headline news that it is right now, when even the prime minister has felt the need to apologise as countless non-urgent operations are cancelled, accident and emergency department waiting times rise and people lie on hospital beds in corridors.

Good sources tell me that St Helier, which lies in Carshalton, at London’s southern reaches, closed a ward recently in an attempt to save money – only to have to reopen it a short while later.

Indeed, my father had been one of the patients transferred into another ward in order to enable that closure, though I didn’t realise it at the time.

At the beginning of November, suffering serious abdominal pain in the night, he used his safety watch to summon help. A scan revealed gallstones and elective surgery was proposed, with the aim of building him up beforehand.

Then his major organs got stroppy. Early on a Monday morning, I was summoned to the hospital as a matter of urgency.

It’s approximately a two-hour trip. Scrambling out of the most convenient railway station and into a minicab, the phone rang again. They were prepping him for emergency surgery. I got there in time to sign the consent form and be told he would die without the operation – and probably with it. The anaesthetist then assured me that, since he would “be asleep,” there would be no trauma. She later told me that she had not expected him to survive the introduction of the anaesthesia.

His Methodist minister, the seriously wonderful Rosemary, was there too and we joked away with him until he was wheeled away. I was grateful that I had, for some reason, I had thought to put sunglasses in my bag.

Rosemary took me to the coffee shop and stayed with me. She didn’t try to be ‘religious’ to me’ but bought me sweet tea and let me burble away.

Ninety minutes later, the surgeon rang to say that Dad was back in the high dependency unit.

He’s a stubborn old sod.

The surgery had discovered nothing. They had expected to find that part of his bowel had died, but instead, realised that he had sepsis. Once stitched up, they started nuking him with antibiotics and, after hours of stabilising has blood pressure, the improvement increased. Within a day or so, he was off dialysis. After a week, he was fully conscious and able to start eating and drinking properly. It is possible that nobody has relished a Fortisip more – he asked for seconds and the look on the face of the nurse was priceless. She was as delighted as she was stunned.

Then Andrew, an Antipodean physiotherapist who walks around the place in shorts, noticed that his right arm wasn’t working. Lots of scans revealed he’d had a minor stroke – and also that he has a touch of vascular dementia. The stroke had only seriously affected his right shoulder and elbow – he can still grip and he still has feeling in his arm. His ability speak and swallow was unaffected.

Because of what the year had already been like, The Other Half and I had planned a short break in Vienna for a combination of culture vulturey and Christmas markets, and a raft of people (including medical staff) insisted I go. Out of medical danger, he asked me to bring him back a CD of Strauss. Johan II, that is. Richard might be more to my liking, but The Waltz King is Dad’s favourite.

While I was away, a team rallied around to make sure he had regular visits and I returned with a six-CD set of Strauss by the incomparable Vienna Philharmonic, conducted by Willi Boskovsky, plus a personal CD player and soft over-ear headphones so that he didn’t have to wait to go home to listen.

He lay in bed, air conducting.

The day I gave him these presents, I waited for over three hours to see a doctor. In the event, it was a physiotherapist who sat down with me to discuss the situation. Sure enough, Dad was going to need to have a bed downstairs at home, with a commode and other aids to help him. He would have lots of physio in the hospital before he went home, including being taught how to use some of these new aids, and then an intensive period of physio at home to help him adjust.

When occupational therapists visited his house to see the situation, they even told me that he would be taken into a kitchen before coming home to see how he could cope with, for instance, a toaster – would it be safe for him, given the dementia diagnosis? He was “top of the waiting list” to be transferred to the stroke ward and he would be home for Christmas.

They’d already told him all this too.

That was the last week of November. He never made it to the stroke ward. As far as I am aware, he made it to any kitchen either – and I have heard nothing to say whether or not he and a toaster are safe together.

He was discharged on 28 December. The 10 days beforehand had enjoyed all the tone of a Kafkaesque nightmare.

Having been told that he would ‘be home for Christmas’ he had focused so totally on that he was distraught.

He talked of throwing his Christmas dinner on the floor in protest at “The Bureaucrats” and how they were keeping him “In Prison”.

He has dementia, remember, and this just bolsters the conspiracy paranoia he’s enjoyed developing in recent years. Thanks, Daily Mail.

As quickly as possible, I had done a part-clearance on the house so that a bed could be brought downstairs – and here’s a chance to publicly thank Jacky from Carshalton Methodist Church for getting people around to do that shifting. I could not have done it on my own.

The process had revealed that my mother had been incapable of throwing anything away or of letting anyone help or move anything. There were empty biscuit tins under a dresser; a carrier bag of empty tablet bottles dating back to at least 2002 were stacked in a corner that was full of other carrier bags that were also stacked full of stuff. If any more floor space had been filled with bags, nobody would have been able to walk around the house at all. I spent my birthday up to my ankles in the mouse poop that was hiding beneath the endless, slowly-decaying bags, but it was done as quickly as I could get people to take away the furniture we needed to shift.

Then, just over a week before Christmas itself, a social worker rang me to see how things were going on. In conversation, it emerged that nobody from the hospital had bothered to contact social services about a care package and that she had simply rung up to get an update on the general situation.

Later that day, at the hospital, the occupational and physiotherapy teams panicked.

They told me that they couldn’t contact social services until all the new aids for him had been delivered to the house. But I had facilitated that at the earliest possible opportunity – and it still wouldn’t have been enough time.

They panicked.

They told me that care packages can be set up and put in place with 72 hours notice.

In an ideal world, perhaps – but not in the one that currently exists. As our own experience in April 2017 had shown and, indeed, as several people who work in the care industry have told me, this is not something that anyone would sensibly assume.

Two social workers have told me since that the 72 hours claim is nonsense and that even if a particular form can only be triggered by devices being delivered to a property, you talk to social services before that so that they can start the assessment process.

The occupational and physiotherapy teams continued to panic.

I’m afraid I got particularly ratty – I have been rather stressed of late, oddly enough – when a physio tried to blame nurses for not having sent a form to social services that they had (it was claimed) been told to send. A doctor told me that this was bollocks – that the form in question is sent by occupational therapy. A professional carer told me the same.

I managed a (surprisingly polite) sotto voce rant.

In the preceding weeks, Dad had been on wards where there was just a single nurse on duty at some points. He did not, from what I have been able to ascertain, receive therapy on a daily basis. He was shuffled between five different wards during his stay, including a final move on Christmas Day itself, when he was weeping and calling out to his dead wife that she should have taken him with her.

All those wards – yet not the stroke one we’d been told he was top of the waiting list for.

As I mentioned eaerlier, he got home just after Christmas. My niece had been down for the week to give me some respite, but she went home on New Year’s Eve.

In the early hours of New Year’s Day, trying to get from his bed to the commode, he fell and lay in his own shit for hours before a carer arrived. Fine whatever reason, his personal alarm didn’t trigger. He spent most of New Year’s Day in A&E before being sent home again.

The following day, he had home visits from two physios, plus a podiatrist. Everyone needed to go through chunks of his medical history each time for their own records. Thankfully, I was there, because he cannot remember everything or simply isn’t always aware of what would be relevant.

Today, he spent the day once more in A&E after a carer realised he was feeling rather poorly. He was dehydrated and probably has a viral infection.

Once again, the staff were fabulous.

Yet so stretched is the system that meals on wheels were not contacted, as they expect to be in such circumstances. They rang me direct concerned that he must have been taken to a different hospital.

There are recurring problems here.

One can ask why so much information has to be gathered so many different times. Is there really no central, complete record that can be accessed by any professional dealing with a patient?

Vast amounts of time are being wasted this way – and there is also the issue of someone such as my father not actually remembering all the correct answers, as happened the other day. If there was time, why not contact family – possibly by email – rather than ringing in the middle of a working day and expecting them to stop everything there and then?

It’s so chaotic that we have had one situation where the new ward he’d been moved to didn’t have any mention on his notes of the dementia diagnosis.

This, of course, requires administration – and we all know, because we have been repeatedly told, that there are too many ‘pen pushers’ in the health service and that they can easily be scrapped.

But that doesn’t make the paperwork go away. This is the paperwork – and if there’s no one to dedicatedly handle it, then it will either eat into the work time of medical staff … or get forgotten.

Communication falls into the same category. For instance, who contacts families to tell them a patient has been moved? In my experience over the past year – nobody.

Last April, when my father was in hospital following his heart attack, he was taken to another hospital for “a procedure”. Nobody told the family. We found out because my niece had come down from the north to visit him – and discovered that he wasn’t where he was supposed to be. I rang the hospital he’d been taken to, but every day for almost a week, I was told he was going to have the procedure that day and then be returned to the first hospital, only to later discover it had been put off until the following day. We could not organise visiting, because we had no idea where he was going to be at any given time.

This time around, Dad’s local pharmacy left a note at the house in November asking someone to contact them, since they hadn’t been able to deliver his medication.

I rang and, having explained the situation, was told that, when he was discharged, the hospital would let the pharmacy know about his medication so that they could organise and then deliver it. This was something else that slipped through the hospital’s net – and I was called by a physiotherapist and told that it was up to me to sort it out. The pharmacy were able to get the new prescription filled and then deliver it to the house – but they had not been notified as they should have been and had had to chase down his GP.

When Dad was admitted to hospital in November, I took a wallet in for him, with a little cash, a note of telephone numbers for close family, a few family snaps and a small prayer on a laminated card that had a tiny cross on it.

On his move to the high dependency unit, it got mislaid. I have asked about it several times – and been back to the original ward too, where details were noted down. I’ve heard nothing. But when staff hardly have the time to do their basic work – I have witnessed nurses almost running around to get key tasks done – how are they supposed to find the time to deal with things like this?

For the avoidance of any doubt: the staff I have dealt with and seen in action have been incredible – patient, caring and utterly committed to the task in front of them.

And my thanks not just to them, but also to the support team – so often forgotten. During his stay, it really helped my father when, for instance, whoever was on the tea trolley remembered him and how he liked his tea, and tried to make sure he got biscuits instead of cake.

Everyone knows the NHS is woefully understaffed and that it’s getting worse. But what I’ve attempted to do here is list here is a series of issues that relate not only to staffing levels – but also to administration.

Too many administrators in the NHS?

No. Not nearly enough.

And the idea that administration is somehow just meaningless ‘stuff’ that will disappear if there is nobody to do it is nothing other than a fantasy that is totally removed from reality.

I very much doubt that this is a unique set of circumstances that add to the difficulties currently facing the NHS. I do not, for one moment, think that what I’ve touched on here is unique to St Helier – and nor do I blame the hospital for what has happened, though it has been incredibly frustrating and has added to stress levels.

But that is why, rather than making a complaint to the hospital in question, I have decided that it is more important to put this in the public domain, where it can add to the swell of evidence on the current state of our health service and to the public debate about what sort of a health service we want and how we get that.

Please feel free to add any experiences of your own below and to pass this post on.

1 comment:

  1. CKD means regular contact with NHS, my sister is a nurse, my sister-in-law a midwife, until she retired my Mum worked in adult social care. I find the NHS a mix of the heroic and inept. I get excellent treatment from hard working staff, but close attention reveals plenty of staff busy doing nothing during my visits. The resourcing of NHS is lumpy, some parts are stretched to breaking point e.g. A&E and those parts overlapping broken adult social care (as you’re finding), but other parts are clearly inefficient with wide variation between good and bad.

    I don't think there is any shortage of administration, it's just poorly managed. Systems used in NHS and care authorities are poor, this not due to underfunding, but poor management has wasted vast sums. Professionally I've worked on many major systems programmes in private and public sector, seen good and bad in both, one is not always better than other, but overall find public sector has a weaker culture when it comes to inefficiency e.g. the level of resistance to doing stuff more efficiently 'because it's somebody's job' even if it adds little value and there are much better ways of using the resource.

    Two things are needed, both will have opposition. Firstly, National Audit Office does wide ranging audit of NHS spending. Secondly, cross-political Royal Commission on long-term funding for both NHS and social care. I don't object to tax going up to pay for health and care, but I think some people who reasonably want more funding avoid existing issues of inefficiency and waste because they think it undermines getting more money, but there will never be a way forward without doing this.