Inevitable consequences

One of the difficulties for the members of any organisation is to ‘see the world anew’ (Albert Einstein). Accustomed to ‘the way things are done around here’, inured to its challenges or simply blinded to its faults through the absence of an alternative view, we keep on doing the same thing not expecting a different result but the same one. We know that what we do won’t work but we keep doing it anyway because ‘that is what we do’.

The following story comes from a friend concerning the care of her father. As always it has been anonymised and my reflections follow:

Hi John,

OK, here goes.

05.00:    My father (85 years old) is found conscious but confused on his bedroom floor. He is unable to get up unaided as he is very weak, dehydrated and has severe osteo-arthritis in his knees. Unable to move him, my mother calls me for assistance and rings for an ambulance. The ambulance service advise that they are very busy and there will be some delay in their arrival. I arrive promptly and, together, mother and I make father as comfortable as possible, but are unable to lift him onto the bed.

06.00:    The paramedic arrives in an ambulance car. He carries out relevant assessments, and manages (with difficulty) to get father onto the bed. He concludes that he requires admission to a Ward/ Old Person’s Unit ASAP. Father is unable to sit up or move himself on the bed, or get to the bathroom, due to weakness and confusion. The paramedic offers two options:

“call a full ambulance to take him to A&E at the relevant hospital”


“wait until the GP surgery opens, request a home visit. The GP can then recommend direct admission on to a ward/ OPU thereby avoiding having the many hour wait at A&E.”

We opt for the latter alternative, which is also the recommendation of the paramedic.

08.30:    I ring the GP. After a long wait in a ‘holding’ queue I speak to the receptionist who advises that the GP will return the call before booking a home visit.

09.00:    The GP calls back, and advises that she will make a home visit once morning surgery hours have closed. During the course of the morning fathers condition deteriorates: he dozes fitfully but is running a high temperature and is unable to eat, drink or use the bathroom.

13.00:    The GP arrives, agrees with the paramedic’s recommendation of admission and starts phoning around the local hospitals/ OPUs in order to get him admitted.

Everyone that she speaks with refuses to take him on the grounds that the local health authority have a policy that:

“elderly people who have had a fall must be admitted via A&E in order to screen them for possible bone fractures.”

The GP is unable to arrange direct admission and calls for an ambulance to take father to A&E. We are advised that this will arrive within the next couple of hours.

16.30:    The ambulance arrives. The two paramedics repeat all the screening tests then stretcher him to the ambulance and take him to A&E. I accompany him.

17.15:    The ambulance arrives at the hospital, but the crew are unable to take father into A&E as there is a queue.

17.45:    Father is taken into A&E to wait in a queue on a trolley for an assessment bay to become free. The paramedics are required to stay with him until he has got into an assessment bay and they can do a formal handover.

A&E is teeming with paramedics all in the same dilemma, forced to hang about waiting to handover their patients. The paramedic informs father that he usually completes one – or on a good day, two – jobs per shift because of the bottleneck in A&E. In a neighbouring service with access to multiple A&E sites, he is able to complete five to six jobs per shift.

19.30:    Father finally reaches an assessment bay, where the handover takes place – this consists of reading out the completed paper work which records measures such as BP, heart rate, temperature recording etc. The nursing staff repeat the tests, and then father is left on a trolley in the corridor to wait for a cubicle in A&E.

20.00:    The patient is moved to a cubicle. Over the next couple of hours father is assessed by nursing staff and a junior doctor

22.00:    The doctor declares that father should be admitted to a ward: but that there is a long wait for a bed. The doctor advises me to go home as it is likely to be a very long wait, and they will take care of him in A&E.

24.00     Father is finally admitted to the Acute Medical Frailty Unit, where he is found to be severely dehydrated and requires catheterisation and rehydration. He was never assessed for breaks or fractures.

Best, M

Now, in the light of my opening paragraph, and assuming clinical competence (as I think we reasonably can because all the right medical things seemed to be happening even if the timing was off!) I can make some key observations:

1:         The process of getting this severely ill man admitted to a bed took 19 hours.

2:         The actual amount of ‘clinical’ attention in that 19 hours can amount to no more than 2 hours at best:

First paramedic assessment– say 15 minutes

GP assessment – say 30 minutes

Second paramedic assessment – say 15 minutes

A&E assessment – say 60 minutes

The other 17 hours were spent waiting.

3:         The critical clinical decision (this patient needs hospital admission) was taken by the first paramedic at or around the end of the first hour, i.e. at 0600.

4:         The ‘options’ offered by the first paramedic were, at best, ill-informed. At worst they could be seen as a device for meeting a target by shifting the problem and closing a case. (I am more inclined to cock up than conspiracy on this one!)

5:         The decision to offer those ‘options’ at 0600 contradicts the recommendation of the need for hospitalisation. While the immediate despatch to A&E MIGHT have incurred a delay, waiting for the GP GUARANTEED an absolute minimum delay of 2½ hours.

6:         Given that the GP was informed of the paramedic recommendation, the decision that the patient could wait a further 4 hours for a home visit is also strange.

7:         The failure of the GP to arrange hospital admission because:

“elderly people who have had a fall must be admitted via A&E in order to screen them for possible bone fractures.”

is odd. How could she not have known that before she started phoning round?

8:         The 1st (0600) and 2nd (1300) clinical assessments needed to be repeated by the (less qualified than the GP) paramedic staff (1630) because the patient had, in effect, been untreated from 1300.

9:         The three hour delay between the paramedic arrival at 1630 and the arrival at an assessment bay at 1930 is unconscionable.

10:       It sounds like there is a ‘queue for the admissions queue’ at this hospital. Presumably the 4 hour treatment clock only starts when the individual is handed over, not when they arrive.

On this one I will opt for conspiracy (or at least deliberate action) rather than cock up – because the paramedic reports it as being a regular occurrence.

11:       The duration of the ‘clinical assessment’ commencing at 2000 is, presumably, down to the length of time it takes to get results rather than to the duration of the assessment process itself.

12:       The failure to fulfil the initial reason given for the ‘process’:

“elderly people who have had a fall must be admitted via A&E in order to screen them for possible bone fractures.”

turns out to be, at best, unfulfilled.

For me, this is a story in which the mental models of those ‘operating the system’ (Paramedics, Doctors, Nurses, Managers) is inadequate to address the problems encountered by themselves AND their patients.

Their model is composed of a series of silos – a paramedic silo, a GP silo, an A&E silo – and within each silo everybody is doing their clinical best, they may even be efficient within their silo and meeting their various performance targets. Meanwhile the patient(s) is(are) suffering. Our case study only features one patient – but there must be many others else there would have been no queue at A&E…………..

Perhaps the challenge is that, even if there is, notionally, a clinical ‘care pathway’ that bridged the gaps between the silos:

Policies and procedures are disconnected from the actual process of caring for patients;

Ambulance, GP and Hospital Processes are fragmented, partial, incomplete or simply disused (through ignorance of their existence?);

There is no evident ‘end to end’ process of patient care from contact through diagnosis to discharge (and beyond);

Information about process is not clear;

Information about the patient is not transmitted between clinicians;

The A&E function clearly lacks basic organisational disciplines around process control and resource management.

“All that is necessary for evil to triumph is that good men do nothing”

Edmund Burke

I think it might be time for the good men and women of the NHS to do something!

So, what does that something look like? Well, it looks like we need to adopt a totally different mental model, one which recognises that the purpose of the health care system is to achieve the desired outcome for the patient, i.e. his or her restoration to health. Then we can design the organisation backwards from that desired outcome. We might adopt a process that could be thought of in the same way as a factory. One in which a ‘clinical pathway’ is a reasonable proxy for a production line. How might that help us to address the challenge?

1:         we would design our production line with a production control system so that we could manage the process as well as the patient;

2:         the operation of the whole would be stimulated by the demand on the system, in this case the phone call to the ambulance service;

3:         we would design the process as a ‘one way fit’, i.e. we would design failure out from the outset (as far as practicable) – and failure would be expressed in terms of the needs of the patient;

4:         a ‘lean’ process (and the best of contemporary production processes are lean) would be designed to draw the patient through the process with minimal waste;

5:         we would understand waste in at least two ways, the under-utilisation of the production resources (people, equipment, space) AND the waste of the time (and possibly the health) of the patient. Essentially, any time the patient is ‘in the system but not being treated’ is wasted;

6:         the process would be designed from end to end and would transcend both organisational boundaries and clinical disciplines (both of those are attributes of the historic origins of the system, neither can be considered entirely fit for purpose from the perspective of the patient);

7:         we would share the information about the patient throughout the process and use that shared information through the production control system – which links me back nicely to the first point!

While we continue to maintain a healthcare system trapped within its habitual functional, disciplined based delivery models we will be unable to realise the potential of our national investment in healthcare and we will continue to see and hear of cases like that outlined here – because those cases are inevitable consequences of the design of the system.