20 December 2009

How the other half lives

It was about a week ago when friends came round to pick up their dog. Mrs Grumble looks after Fido while they are on their yacht. Not many of Dr Grumble's friends have yachts but these friends do. Miriam is a housewife and Timothy works for a large accountancy firm. You would all have heard of this firm. It's big. It's global and from time to time it is called in by the NHS for audits or to tell us we are inefficient and need to sack staff. That's how they make their money. That's why Timothy has a yacht.

But this is not about jealousy. The weather is too cold for yachting. Dr Grumble would prefer to walk the dog in the snow than be out on the sea. Besides Mrs Grumble gets seasick. This is about something seasonal which irritates Dr Grumble year after year after year.

About a month ago Edward Grumble, who is an F1 doctor, phoned up and in a bewildered voice explained to Dr Grumble that he would have to work over Christmas. Not just a bit of Christmas but all of it. It seems that even Edward Grumble, Dr Edward Grumble, thinks the patients go home for Christmas. This expectation of having Christmas Day off is a new thing. Dr Grumble's own staff seem perplexed that they might have to work on Christmas Day. When Grumble was a house physician he knew he might well have to work at Christmas because we all worked virtually all the time. That may sound bad but things are much worse now. You see in Grumble's time there was a doctors' mess where they really looked after you. On Christmas Day you would get a turkey. An enormous whole roasted turkey to carve. And before your Christmas lunch you would be on the ward with more proper turkeys that the consultant surgeons wearing chef's hats would expertly carve for their patients. Christmas in the hospital was fun. The consultants came in laden with presents. Sherry was drunk on the ward. Nobody minded if you had a tiny glass. There was a wonderful camaraderie.

Fun has long gone from the average NHS hospital over Christmas. Things have changed. Thanks to Timothy's company we now run lean wards. Lean is, of course, a euphemism for thin. Skeletal would be more accurate. The juniors can't stop for a moment any more. Skeleton staffing means they have too much work. Traditional firm structures have been destroyed. There is just no time for fun. Especially not at Christmas. There's no way you will get a turkey to carve. You will be lucky if the food vending machines are filled. Where Edward Grumble works in a large university hospital it must be the same. When Mrs Grumble telephoned him yesterday she asked what he was doing. He was in Marks and Spencer buying a Christmas dinner ready meal for one. How sad is that?

Anyway Timothy and Miriam came back from their day's yachting last week and said they were thinking of throwing a party on 29th December and they might not hold the party unless the Grumbles could come. Now that's a wonderful compliment but it started making Dr Grumble's hackles rise because it was clear that Timothy's company had given him the whole week off. Dr Grumble immediately apologised and explained that he had a ward round followed by a clinic. He would not be back in time for the drinks. The 29th is a normal working day in the NHS; getting to a party is just not on. A look of utter bewilderment went over Miriam's face. It was as if she had never heard of a ward round. She almost seemed suspicious that this was a quickly thought up excuse. Nobody could possibly have work to do between Christmas and the New Year. Mrs Grumble gently explained that she too was working. Like Dr Grumble she has targets to meet. In her case the target is two weeks which is tight. You can't have a week off over Christmas and meet your targets.

Who are these people who tell us that government services are inefficient and their employees mollycoddled? Try telling that to my neighbour whose daughter will be fighting in Afghanistan over Christmas. Compared with some, Dr Grumble and his family are lucky. Very lucky.


Prisoner of Hope said...

You might be interested to reflect - on the 2 worlds that you describe so well - by seeing what some of us in Sheffield are trying to do to not only draw attention to this sad state of affairs but also to see if we can do anything to shift local policy, based on the well researched evidence contained in The Spirit Level: Why More Equal Societies Almost Almost Always Do Better. The FAQ section includes links to 2 other relevent books that have a bearing - The Culture Of Contentment by JK Galbraith and Trust: How We Lost It and How To Get It Back

Nurse Anne said...

When I first started working for the NHS as a nurse we got a £20 pound M&S voucher from the hospital at christmas. Now we get nothing. And if relatives or patients give any gifts management takes them and we don't see them again.

Canteen will be closed, there will be no food in the vending machine and no time to stop and eat anyway. I have a microwavable cup of soup for my christmas dinner in case I get time.

English Pensioner said...

I worked in the air transport industry, and I would estimate that probably 75% of us had to work weekends and bank holidays, from the Engineers, like myself, Aircrew, Air Traffic Control, Baggage Handlers, Check-in staff, etc, etc.
Now logically, there is no need for a 24/7 airline service, people might be inconvenienced if they couldn't fly at weekends or bank holidays, but it is unlikely that anyone will die or be in serious pain because they can't.
Yet the NHS, which in my view should be a 24/7 business just seems to pack up and go home at these times, to call it "skeleton staffing" when hospitals are all but closed is a gross overstatement!

Dr Grumble said...

My neighbour (on the other side) is a pilot. He has all of Christmas off and seems to be at home most of the time. He tells me that his brother who is an orthopaedic surgeon works very much longer hours.

But I agree that there are many others in the airline industry that seem to work long awkward hours and the NHS does have a problem with its 9 to 5 culture.

Hospitals should be operating a seven day week. This would enable investment on expensive scanners to be recouped as well as being more convenient for patients. There are various reasons why this does not happen. Managers see the problem as being insoluble but I see no evidence that they have tried.

Nevertheless there are 168 hours in the week and most of these are out of hours. When GPs decided not to cover the out of hours in their spare time, it was not easy for the powers-that-be to provide alternative cover. It's not easy for the hospitals either as a lot of doctors hours have been lost as a result of the EWTD.

English Pensioner said...

The point that I was trying to make is that there are numerous areas where people have to work at all times, either from necessity, such as in the electrical generation/distribution business, or from commercial imperatives, such as supermarkets and the airline industry.
Unfortunately, whilst the NHS should fall into the first group, along with the Police & Fire Services, I feel that it simply fails in its responsibility.
Incidentally, I worked an average of 3½ 12hr shifts,a week, some at night or weekends which resulted in the neighbours thinking that I was always at home and had a soft job!

Dr Grumble said...

I have patients who work for a large airport. They work long very unsocial hours. My pilot friend admits his hours are short but they are very antisocial. To my surprise every year he seems to have Christmas off.

In general it is coalface workers who have to work over Christmas. The manager and consultancy types mostly just set up the systems and take a lot of time out over a surprisingly long break. But even some coalface workers abandon their work at this time of year. Try getting your car fixed over the next week. We will be holding routine clinics next week. My only complaint is the the patients won't turn up. I have told the managers this but they just won't believe me.

A said...

Your point about the weekend (and overnight!) is sound.

Our hospital (a large university institution) has recently announced that the radiology department are not willing to support out-of-hours stroke thrombolysis.

What's the point of offering a cutting-edge service if it's only 40 hours our of 168?!

Dr Grumble said...

I'm afraid it is always radiology departments that stymie such initiatives. The emergency department is prepared to do it. Acute physicians are prepared to do it. Even neurologists are prepared to do their bit. But in the UK anyway radiology departments dig their heels in so that you end up running a service 40 hours in the week when there are in fact 168 hours to cover.

There are various reasons for this. I will leave others to comment (if they want to) on what those various reasons might be.

Anonymous said...

Anyone like to tell us how much radiologists are paid and how long they have to train for?

Happy1 said...

Being a police officer, my brother also has to work Christmas Day, and some of the other other sociable festive days.

Only he gets an £800 Christmas bonus for it! And time and a half, and time in leu!

Us NHS slaves get nothing :(

Dave Hughes said...

Radiologists: NHS consultant salary (good private practice opportunities if they swing that way). Training is as for most specialties, under the old system would be 6-8 years as a registrar, usually having been a med\surg SHO and done MRCP\MRCS. Now there's run-through so likely to come out more quickly (but less sympathetic to the hapless medic on the other end of the phone?).

Nikita said...

Radiologists. They must not have a consciece. Nine to five OK - bugger the patients. Why does the NHS allow it?

Have a Happy Christmas, Dr. G. I personally, will not be woking and am grateful to my colleague.

Kind regards,

Mags. xxx

pj said...

The poor quality of out-of-hours cover in the NHS is a disgrace. This year, as every year, even every night and every weekend, people will die because the skeleton staff working at night, or at weekend, or in this case over the 4 non-working days of Christmas are simply unable to adequately cover acute admissions on top of the management of the existing patient population with minimal other services (e.g. radiology or pharmacy) available to them and generally poor senior support.

It would be silly to argue that a 24hrs regular service needs to be provided (since the majority of patients sleep all night) but access to services over the weekend with adequate staffing levels at peak times (e.g. 5-10pm) would go a very long way.

This weekend I shall be happy just to keep the patients alive until Tuesday and myself from crashing the car on the way home.

Dr Grumble said...

He was in Marks and Spencer buying a Christmas dinner ready meal for one. How sad is that?

It turns out to have been even sadder. Edward Grumble couldn't find a Christmas dinner for one. He is going to have tagliatelli. If has time to eat. There are no phlebotomists or nurse practitioners working on Christmas Day so the junior doctors as well as doing their own work are going to have to do the work of others. His handover sheet is 9 pages long. It sounds as if he is going to have more work that he can possible do in the time available.

A said...

The irony, of course, is that you're now better off having a stroke outside our sister DGH 25 miles away. It has radiology staff who are prepared to do the scanning 24/7!

the a&e charge nurse said...

"There are no phlebotomists or nurse practitioners working on Christmas Day".

Au contraire, Dr Grumble - we A&E quacks work EVERY DAY of the year, and although I am not working this Xmas, I will be starting nights on New Years eve.

Anyway, thank you for some marvelous posts - please keep the blogging flag flying.

Merry Xmas to all of the Grumble aficionados.

Dr Grumble said...

We A&E quacks work EVERY DAY of the year.

A good feature of targets are that they prevent managers from cutting staff in some areas such as A&E. Ward phlebotomy has always been a Cinderella because the only people that really suffer from cuts are the most junior doctors.

the a&e charge nurse said...

"A good feature of targets are that they prevent managers from cutting staff in some areas such as A&E".

Yes, Dr Grumble, we have been lucky enough to see an increase in our establishment (of senior doctors) but not all A&Es are expected to survive in the current climate.

Perhaps in the coming months we will rely on the bloggers more than ever to supply bulletins about how life in the NHS really is?

Dr Grumble said...

In the Grumble view it is quite right that not all emergency departments should survive. If Grumble was really ill he would prefer to travel further to get to a decent emergency department rather than be treated locally.

At Dr Grumble's hospital they reckon to be able to deal with major trauma but there is a hospital down the road which can do the job better. Having systems to deal promptly with major trauma is costly and not every hospital has the right infrastructure. Rationalisation is the way to go but the public never want their local emergency department to close and professionals whose jobs may be at stake also tend to resist closures.

Dr G has lost count of the number of places where he has worked where there have been 2 or 3 hospitals where there should only have been one with all services under one roof. The NHS has always failed to rationalise. As always political considerations get in the way of the difficult decisions that are needed.

the a&e charge nurse said...

"it is quite right that not all emergency departments should survive".

Well, the Whittington saw 85,000 patients last year (and probably more again this year) - where will they all go after closure?

A quick survey of the local scene identifies immediate and self evident problems.

Barnet A&E was designed for 40,000 patients and now sees nearer 80,000.
The North Middlesex is one of the biggest (and busiest) departments in London already seeing in excess of 125,000 patients each year.
The Royal Free and UCH can barely cope as it is.
Chase Farm is in the process of being downgraded.

Don't forget, very serious trauma accounts for a tiny minority of patients attending A&E, although admittedly past management has been far from ideal (in some cases).

So, London will have its x4 major trauma centres (St Marys, St Georges, The London & Kings) and one assumes this will improve outcomes for a certain quota of patients, assuming they don't die in the back of an ambulance while local providers deliberate if the injury is 'too serious' for it to be managed at a second tier service?
For example, stabbings can result in anything from a few stitches to a life threatening bleed.
How will it be decided (and by who) which patient goes where?

Is 'rationalisation' a price really worth paying given that those with vague symptoms amongst a population of 10's of thousand (such as prodromal meningitis, deranged potassium, or atypical MI, etc) will have to fight even harder to find an A&E that is not jammed to the rafters?

We shall just have to wait and see which way the mop flops but the logistics (as presented above) virtually guarantee that somebody, somewhere will suffer while fighting for appropriate medical attention?

Dr Grumble said...

It's not Dr G's area of expertise a&e charge nurse. Plainly you are more expert in this field and your points do seem sound.

Grumble sees only the few sicker patients that arrive in A&E. But do the less sick patients really need to attend a hospital at all? Wouldn't the old fashioned GP have dealt with them adequately (or maybe better) in the past? And are the problems you describe countrywide or are you describing a London problem?

Could the problems you describe be contributed to by problems in delivering quality out-of-hours primary care in London? Certainly Grumble is aware of large numbers of admissions from private nursing homes and other admissions which in the past would have been managed by a GP without admission to hospital. But quite often no GP has been involved or some out-of-hours GP who does not know the patient has just sent them in. Yet for many of these patients looking after them and keeping them comfortable is really what is needed and not the inevitable CT PAs and troponins.

Why are A&E attendances increasing? Why are hospital admissions soaring? Are there really more ill people around?

Grumble does not mean to imply that he knows the answer to these questions but he does wonder if perhaps we could do some of this unscheduled care better.

the a&e charge nurse said...

I must admit I was a bit surprised by your suggestion that A&E departments need to be 'rationalised', Dr Grumble.

To my mind it was on par with those who have suggested that we need fewer hospital beds

What is Northern Doc to do with his incontinent patient after the local A&E shuts down?

Dr Grumble said...

Maybe old Grumble is succumbing to the managers' blandishments.

With regards to hospital beds there are now vastly fewer than we had in the past but even in the past there were never enough. The US has even fewer beds than we do. Other countries have many more. If you wander around the wards you will rarely see an empty bed but you will also find very many patients who really should be somewhere else. Similarly I suspect many patients who attend A&E could have seen their GP and many patients admitted from A&E have social rather than medical issues. Also you will find that many patients are unable to go home because of social problems that they had long before they were admitted. Hospital is often used as a place of safety when there is nowhere else for the patient to go. Now that may be alright because wherever they go somebody has to be paid to look after these people and that somebody is likely to be the taxpayer in one form or another. On the other hand alternatives might be cheaper.

Eileen said...

Both my daughters are in the NHS (a ward nurse and a paramedic). The nurse has children and her husband works for the ambulance service too. Friends have asked me for years "are the girls coming home for Christmas" - and gasp as I point out they are always working. If not on Christmas Day itself, then Christmas Eve or Boxing Day - no time to go anywhere. In fact they often volunteer to work so others can spend time with their families - or the branch in Scotland do New Year's day for the benefit of those who have a hangover.
But you're right - 35 years ago Christmas in hospital was wonderful. We had days of Christmas dinner because absolutely EVERYBODY went to the canteen for it. And surgeons were really rather good at carving turkey.