Equality of services across the country

The news today is full of stories about people in rural Cornwall being unable to access immediate investigation and treatment for stroke which results in poorer outcomes compared to their city dwelling contemporaries who will have their heads scanned, their thrombolysis up and running and be back in the queue at the chip shop before you can say “brain attack”. Outraged members of the countryside are spitting with rage at the inequality of this, stroke charities insist that something must be done. Not wanting to be left in the shadows, cancer is also bumping it’s gums and pointing out that you will be diagnosed later if you are from the middle of nowhere.

I have a different view on this, which is that it is unaffordable and insane to want every hospital to have every possible expert physically there all the time in case someone needs their attention. We cannot staff and equip small hospitals in the same way as Bighospitals.

People in the UK have a perverse love for their local hospital, where they were probably born and had their broken arm seen to when they were 12. They declare the surgeons there “very good” with no grounds for that assertion. The chances are that the surgeons there are average surgeons (something none of us think we are) and are competent and reasonable individuals. It is most unlikely that they are the best, most unlikely that they are offering cutting edge treatment and most unlikely that they have the best outcomes. This is not because they are different in any way but because they will not have the back up of umpteen specialist cancer nurses, a 20 bedded ITU, a 40 bedded HDU, CT scanners that run night and day and in house dialysis and interventional radiology.

How can we convince the public that they want an operation from someone who does that particular operation all the time backed up by a team that looks after people like them all the time? I might be able to do a liver resection (I’ve seen enought of them and done a few with someone talking me through it) but I am clearly not the best at it and if you want the optimal short term and long term outcomes from your surgery then you really want the best as opposed to the nearest person wielding the knife.

In the UK this approach is political suicide. If the government announced centralisation beyond what we already have there would be much public wailing. If you even suggest to the public that you plan on closing a so called A&E department staffed by a bunch of staff grades, GP’s, junior doctors and nurse practitioners with a Skype link to the nearest hospital for tricky questions (I kid you not, this happens) and ask the public to travel 9 miles to the nearest Bighospital where a team of 17 consultants and 40 juniors and a CT scanner in the department await them, you get a riot. Nobody wants the best treatment if it means a drive to get there. They all want to travel five minutes up the road and access the best care in the world, 24 hours a day, 7 days a week, free of charge.

I wonder if Jeremy Hunt or any health secretary will ever have the balls to say to the media and the country that this is impossible. What we should be doing is improving the rate at which these services are accessed, improving the transfer of patients to and from the best centers. If you have a stroke in Cornwall, helicopter or ambulance services should be able to get you to the right place to receive your thrombolysis. Similarly with cancer investigations, if you need a CT scan your GP should be able to access that and arrange it accordingly.

Bighospital takes people from a large geographical area, they often lament traveling to us and ask why nobody at their local hospital can do the liver transplant they need or why they can’t have a stent in their superior mesenteric artery their either, as though these skills are commonplace. North Americans seem to be more in touch with the concept of healthcare being expensive, that it requires highly skilled individuals who have trained for decades, that you want the best surgeon, best hospital, best nurses and expert anaesthetists doing your operation. We in Britain seem to prefer the nearest person.

setting a good example

setting a good example

It is fun to have a goal and fun to do your best in every part of your job. I have recently been all about inspiring loyalty and building my team. I think I have achieved that; the first day my FY1 seemed irrate that she didn’t leave at 4pm, her paid finish time. I’ve made a huge effort to make her feel valued, supported and taught her as much as possible. Today when I offered to let her go at 4pm and do the ward round alone she declined, seemingly horrified that I might go round without her. 
How have I achieved this miraculous turn around? Dead easy; I’ve listened to her, bought her coffee, remembered her name, her boyfriends name and been available and listened to her every time she has called. I’ve involved her in a project, sorted out some meetings she might like to attend, asked about hobbies and interests.  

Why haven’t I done this every time I’ve had a new junior you may ask? Well, it’s because I am only now secure and relaxed about how I do my job, how to run the ward, how to look after sick people how to organise myself etc that I am attending to these other “extras”. 

I have also embarked on some audits. One audit is hugely dull and to do with post operative management, the other is much more fun. In part it is inspired by Kate Grainger and her “hello my name is” campaign as it really shouldn’t be just patients that we introduce ourselves to but our colleagues as well. 

So far senior colleagues are not coming out of this well, consultants seem to think we should know who they are already. Radiology are the worst offenders for this and so far 80% of radiologists have failed to say their name when my “audit data collector new person” pops down to arrange a CT and introduces himself. Poor show from the doctors of darkness, perhaps it’s a deliberate ploy, if we don’t know your name how can we hate you? 

I have always been keen on being easily identifiable and I like to write in the notes my name, pager and designation as well as who the consultant on call is that I am acting on the behalf of. This seems to be a rather old fashioned quirk of mine and none of my colleagues do this anymore. 

Introducing yourself and being polite is not weak, it isn’t “inappropriately friendly” it is good manners and common sense. I don’t believe that anyone in another profession would be so rude. I don’t think that this is a quirk of Bighospital although Bighospital is big and therefore unfriendly, as it happens in other hospitals too. 

I have decided that instead of getting pissed off at core trainees that can’t diagnose appendicitis in children and FY2’s who forget to prescribe the gentamicin I am going to focus on their non medical skills. I want them to be polite, to know the names of the nurses, the pharmacist and the medical staff and to make Bighospital a nicer place to work.

It’s taken me rather long to reach this basic conclusion.  I didn’t know that I had the power to change it and that I could lead by example.