20 June 2009

Useless Follow-ups

There are important messages in medical blogs. Sometimes you see things written that you have seen nowhere else before. Yet you may have had exactly the same thoughts yourself. This makes you feel very close to the writer because you have the feeling that at long last somebody thinks in exactly the same way as you do. It can make the blogosphere addictive.

Dr Grumble read a post this morning that struck a real chord. It was written by a GP but the message was one Dr Grumble felt he could have written himself. It was critical of a certain aspect of hospital outpatient care. Since Dr Grumble is a hospital doctor you might think he did not take too kindly to this. In fact it referred to a problem that Dr Grumble has been aware of for a very long time. The Jobbing Doctor was having a moan about the patient for whom little can be done who attends the hospital regularly, sees a junior doctor who does not know what to do (because nothing can be done), orders a useless test and arranges for the patient to come back after a few months when the junior doctor will be in another post.

Dr Grumble has no doubt that this has been a problem. Some years ago he discharged a whole swathe of patients with a chronic condition for whom he thought that the trip to the hospital was not worth the shoe leather. They quickly persuaded their GPs to refer them back. If patients have been led to believe that they need frequent hospital attendance it can be difficult to persuade them otherwise. The fault was in ever establishing this pattern of care.

Dr Grumble thinks this is now much less of a problem in the Grumble hospital. The example the Jobbing Doctor chose was of a patient with ischaemic heart disease for whom everything that could be done had been done. Dr Grumble would defend his cardiological colleagues. They rarely follow up patients like this. They rarely have any junior doctors in their clinics. They focus their expertise where it is needed.

Perhaps the hospitals in Jobbing Doctor's neck of the woods are different. The Grumble hospital has tight targets to meet. One of them relates to the ratio of new patients to follow-ups. If you follow up patients that don't need it the hospital won't get paid. Some of Dr Grumble's colleagues complain bitterly about this. Dr Grumble thinks that it focuses the mind on the need for follow up. Dr Grumble's new-to-follow-up ratio is excellent. The Jobbing Doctor would approve.

If professionals don't do things as they should you cannot blame managers for forcing them with targets. Targets are not altogether bad.


Jobbing Doctor said...

We are struggling to rein in the clinical activity of our sole provider NHS trust as they clearly feel that the PCT is a milch cow to be milked for as long as possible. We do not have a new-to-follow-up contract and they are not playing ball on this.

I agree that cardiology is a bad example - the worst is elderly care, whose quality, clinical decision making, communications and judgement remain very poor.

I resent that we have to pay for useless follow-ups from our budgets.

The money should be better used.

Dr Grumble said...

Hospitals have always done work that did not need to be done even if it did not generate an income. The old system was not always good at dealing with this.

Unfortunately if you have a market the more work you do the more you get paid. That is only good if the work needs to be done. That is a big problem with markets. They often succeed in selling things that aren't actually needed. The managers don't care as long as we succeed in getting your money.

The NHS is beginning to develop all the defects of a private healthcare system.

I would have thought that unless geriaticians are based in the community GPs would be better placed to deal with the long term problems of the elderly. We have a community-based consultant but whether this works or not I do not know.

We have some very major elderly care issues that are not being dealt with by GPs. Patients at the end of their lives are being bundled into hospital out-of-hours where they are being given intensive treatment when the focus should be on keeping them comfortable. It's not what I would want to happen to me if I live to reach that stage.

I suspect that privatisation of the care homes and GP OOH may have a part to play. Certainly it used not to be like this.

the a&e charge nurse said...

Dr Grumble said ....... "Patients at the end of their lives are being bundled into hospital out-of-hours where they are being given intensive treatment when the focus should be on keeping them comfortable".

Hear, hear, Dr Grumble although it is hard sometimes, to express such views without sounding like a eugenecist.

Not a day goes by when a procession of elderly, often demented patients are brought into A&E from a substandard care home without any medical assessment having been carried out in the community.

I suspect there is simply too much work for GPs to cover but if I'm honest I do not think acute hospital is the best place for such patients.

Personally I would prefer if we were all more honest and open about when too much medicine can become a bad thing - my own advance directive is shaping up nicely.

Dr Grumble said...

It is easier for the care homes to send them in and it is easier for the hospitals to treat them rather than do what the patients would want for themselves if they were able to tell us. It is more the fault of those outside the hospital than those within. Once the patient is sent in there is an expectation of treatment and deciding that the right thing for the patient is not to treat is more difficult if you do not know them or their relatives. The decision should be made before the issue arises as making such decisions in the middle of the night when those that really know the patient are not easy to contact is fraught with difficulties. Yet many of these patients are admitted repeatedly through the A&E revolving door. Pressure to discharge quickly means that the hospital does not have time to agree a plan with those involved for what should happen next time.