Written evidence submitted by Malcolm Perkin (FGP0227)

 

Three suggestions to improve the efficiency of general practice and the wider NHS

 

 

I am a retired doctor. During my career I was a GP (1975-2021), an out-of-hours doctor (1974-2019) and a Director of Public Health (2002-06). I learned care of the elderly from Professor Grimley-Evans when I was his houseman in 1973-4.

 

This submission differs from some others you will receive, in that it sets out how some aspects of primary care – and therefore the NHS – can be improved without the need for much extra funding.

 

The three suggestions set out below cover:

 

 

A BETTER PATHWAY FOR ACUTELY ILL FRAIL PEOPLE

Here is an anecdote.

The elderly lady lived alone in her own flat, in a warden-controlled building. She could get about using a walking aid. One night she fell on her way to the bathroom, and injured her foot against a radiator. The care worker phoned 111 and asked for a doctor to visit. The out-of-hours GP came, and asked for an X-ray, as it was possible a bone in the foot was broken. The ambulance was called. The paramedics took a full history and recorded vital signs. They transported her to A&E, where the X-ray was taken. There was possibly a small crack in a small bone in the foot. She stayed in A&E overnight, and next morning the care of the elderly team did a thorough assessment including all her existing conditions and any factors that might make her prone to falls. An orthopaedic registrar came to see her; he took the history, examined the foot, and looked at the X-ray; he advised there could be a small chip fracture, and prescribed a moon boot. She was admitted to the ward to wait for it. While there she had a social work assessment. Unfortunately she had to stay in bed on the ward because there weren’t enough trained staff. Meals were put on her tray, but she didn’t eat much and wasn’t helped at mealtimes. However, she was helped into a weighing chair to document if she was losing weight. Once the moon boot arrived she was discharged and taken home by ambulance. She couldn’t put the boot on because it was unwieldy, and she couldn’t walk in it because it was too heavy. No cause was found for the fall. A community physio visited two weeks later but by then she was walking on her own as before.

Question one: how many people asked for an account of her fall?

Answer: care worker, 111 operator, out-of-hours GP, paramedic, A&E doctor or nurse, care of elderly consultant, orthopaedic registrar, ward staff, social worker, community physio = ten.

Question two: the monetary cost of this episode?

Answer: don’t ask – it’s enormous.

Question three: risk analysis of her care?

Answer 1: risk to the patient. Any admission is hazardous for frail people (strange environment adds to confusion, weakness and falls occur after being kept in bed, weight loss due to not eating, distress); presence or absence of a fracture was irrelevant, as it was not amenable to effective treatment; more serious foot injury or other medical conditions would have been picked up by the detailed examinations (if present); serious lack of support at home would have been picked up by the social worker (if present); failure to get back to walking would have been picked up at two weeks by the physio (if present).

Answer 2: risk to the professionals – would they be blamed or censured or sued? Care staff had to call the doctor, doctor had to get the foot X-rayed, paramedics had to assess before transporting, A&E had to keep patient until fully processed, care of elderly team had to do full assessment, orthopaedic registrar had to diagnose and treat, social worker had to see frail patients routinely, ward staff had to weigh everyone …

 

There is a population of patients, mostly elderly, with long term health conditions and varying degrees of disability. Most of this group, most of the time, are coping – in other words, their medical care, living arrangements and social support are adequate for their needs, from day to day.

All the time, however, a small proportion fall out of equilibrium, typically because of a new or worsening medical condition or an accident (also when their housing or community support arrangements get disrupted).

Many of the people who find themselves in this situation are in big trouble. They require immediate help and care; but after that, sadly, not all will get back to where they were before, and they will then reach a new equilibrium – with perhaps more medical input, different living arrangements, and extra social support – in keeping with their reduced state of health.

What is sometimes forgotten, though, is that at any given time the size of this group is not large. On the contrary, patients going through this transition make up only a small population of all those with long term conditions. They just happen to cast a big shadow at the moment, trapped as they are by delayed 999 responses, queues at A&E, bed-blocking, shortages of carers, lack of affordable care beds, and so forth. When the sun shines from a new direction, the shadow will shrink.

In the long run, maybe each town needs two new buildings: an accommodation block for its foreign care workers, and next door to it the community hospital where they look after the town’s frail elderly patients. One suspects, however, that this arrangement may take some time before it gets political support, public approval and funding …. so the queue of people waiting for a care home bed and/or care home funding is likely to be with us for the foreseeable future. This raises the question, is there anything we can change now? Well, there is. It’s the process for handling new cases, the way the system copes with them – it should be more efficient.

 

A multidisciplinary frailty team with community and hospital elements is proposed.

Frail patients taken ill in the community are identified; typically they are the patients whose medical history or poor mobility stops them from coming to an ordinary treatment centre. They are visited at home by a member of the team. The home visit has to take place more or less immediately, because it is sometimes a substitute for a 999 ambulance.

The visiting clinician has two questions to answer:

(1) does the patient have an acute condition that would benefit from immediate hospital admission (bleeding, stroke, sepsis, myocardial infarction, serious arrhythmia, major fracture, etc. etc.)? If so, they are admitted directly to a ward (not A&E) by ambulance.

(2) if the patient isn’t for immediate hospital admission, can the patient’s usual carers cope tonight, or will they need professional support? If needed, nurses and care workers from the team are alerted and will start caring for the patient right away. Normally their involvement will last only until the patient is transported to the frail person assessment unit, usually the next morning and always within 48 hours.

The transfer will be made by the team’s own transport service, who will be trained to move patients by wheelchair or stretcher if required (although they won’t need to be fully qualified paramedics). The patient will go for assessment accompanied by a team member’s evaluation of the home environment and current care requirements, and by a relative if possible.

At the assessment centre, examination and investigations are done at the first visit, leading to a full diagnosis and care plan. If possible the patient is discharged home directly, with treatment and support, otherwise to a ward or step down bed – clearly the flow of patients needs to be carefully maintained to allow this – some patients who should ideally get a hospital bed may unfortunately have to go back home for the time being if none is available. But at least they will not be blocking cubicles in A&E or waiting in an ambulance, and they will have been fully assessed, and they will have started treatment, and their carers will have been offered advice and support.

 

 

OPEN ACCESS PRIMARY CARE

At present, accessing NHS care is hard work for the ordinary patient in the community. All four traditional routes to a clinician have become difficult to use (GP surgery, out-of-hours service, wait at A&E, call an ambulance). Patients often report that they are blocked from face-to-face consultations, that telephone triage is infuriatingly inefficient, and sometimes they get no clear answer to even the simplest question.

 

The alternative proposed here is to set up a large clinical treatment area, in each town, which patients can access by just turning up. Rather like a walk-in centre, but with much more capacity. All ambulant patients with acute problems could be directed there, thus freeing GP surgeries and the 111 service from long queues of patients waiting for telephone triage, and freeing paramedics and A&E departments to deal with serious injuries and life-threatening illnesses.

 

The new service would see everyone who presented, 24/7, so it would subsume the existing out-of-hours services, Of course, it would need to offer high capacity and rapid patient throughput.

The patients would be triaged on arrival at the door, probably by an experienced nurse. A few with serious symptoms would need immediate assessment and treatment. Social distancing and Covid testing would be in place. Patients would wait to be seen – but not passively – instead the waiting time would be used (by a healthcare assistant) to clarify past medical history, current symptoms, and expectations of today’s encounter, plus baseline clinical measurements, and where necessary patients would be helped to prepare for examination. The clinician would then undertake a streamlined consultation (history and examination in the usual way, discussion of diagnosis and management), It would be quick because the patient and their information would be ready. Immediately afterwards the clinician would move on – leaving physician assistants and clerical staff to arrange prescriptions, issue patient information sheets, book investigations, and plan follow-up if needed. Rapid patient throughput would keep waiting times short.

This new service would be a honey pot for the public (who would get quick and easy access to a single effective consultation), and a carrot for clinical staff (who would relish helping patients in a cheerful, low admin environment). For the NHS, it would be a godsend, because it would allow a ‘get it right first time’ approach, and around 90% of acute primary care illnesses could be diagnosed, treated, and out of the way in one short encounter.

Who would staff the system? GPs and nurse practitioners, out-of-hours doctors and nurses, paramedics, nurses and healthcare assistants, clerical staff retrained from 111 duties – quite a lot of them might still work part time in their previous roles, but fewer hours would be needed there because the pressure would be off. GP surgeries and community teams would, of course, continue with their traditional roles, including anticipatory care for long-term conditions, medication management, and follow up of patients discharged from hospital; they would also follow up patients from the new acute service if clinically necessary.

 

 

ACHIEVING HIGHER PRODUCTIVITY BY (REALLY) REDUCING BUREAUCRACY

 

“The currency of NHS management is cost, while the currency of patient care is time.”

 

Over the last 20-30 years there has been a marked fall in the productivity of the NHS, brought about by a gradual accumulation of administrative changes.

The latter is sometimes characterised as “too much red tape and bureaucracy”, but this phrase doesn’t do justice to the scale of the problem. It skirts over the enormous adverse impacts of low productivity, leading as it does to rising NHS costs, poor patient experience and low staff morale.

 

However, on the positive side, the Health and Social Care Committee’s current work on the future of General Practice provides an opportunity for the root causes and the adverse effects of low productivity to be scrutinised.  The goal is a new NHS, running smoothly, with less treacle.

 

Actually, some of the treacle was introduced deliberately – not with the intention of damaging the system, of course, but as part of well-intentioned management initiatives – which were not piloted or assessed for their unwanted effects on patient care and on the behaviour of the system.

 

Examples include:

 

What should be done? It’s up to the top brass, of course. This is their opportunity ….

One of the more radical approaches would be a pilot scheme allowing the NHS to turn to local management – for example, by creating the post of area NHS director, and freeing the holder of such a post from an obligation to follow central directives if they had an adverse impact on clinical efficiency.

 

There are other possibilities. It might be beneficial to insist on cost-benefit analysis for each new process before it’s introduced (clinical time lost vs. patient gain).

 

Example one.

Each doctor and nurse in primary care has to do mandatory training every year, in areas such as cardiopulmonary resuscitation (CPR) and safeguarding. Have you ever looked into a room of clinicians receiving this training? There are, say, fifty health professionals, sitting there for three hours. This represents a loss of about 900 consultations that day in that locality. Yes, there should be CPR training and safeguarding training, of course – but by what yardstick was the decision made, that it should be mandatory and that it should be every year?

 

Example two.

The patient had cancer. It had spread to his spine and other bones. He had just been discharged home at short notice and as the duty doctor I went to see him the same afternoon. This was a big decision, by the way, because he lived in a rural area and the drive there took twenty minutes each way. He knew he was dying. When I asked what was his worst problem, he replied constipation! You can understand this. He was weak, he had been in a hospital ward short on privacy, and he was on opiate drugs which exacerbated the problem. He needed an enema. When I got back to the surgery, I tried to arrange it by ringing the community nurse. No joy. All referrals must be in writing. I must complete a form. The form needed to be faxed. We had no copies of the form to hand. Eventually, though, it was done. It turned out that my consultation with the patient that afternoon was his last, because he deteriorated the next day and was no longer able to speak; he died a short time later. I think the twenty minutes I spent with him and his wife that day did some good, as he neared the end of his life. Coincidentally, this was the same length of time that I spent on the referral form.

 

Examples like this are often dismissed with a shrug: unfortunate events, grumpy clinicians, unrepresentative anecdotes. But they must be heeded, because they are legion. Unnecessary tasks not only steal time from patients but also demoralise clinicians. Just ask, and every doctor or nurse can give you many examples. The solution? Make the people responsible for these administrative changes come to the coalface, because at present many never do; their perception is that they’re only making a small change, and it’s introduced for a good reason, and in any case it will only occupy  clinicians for a short time.

 

CONCLUSION

The three initiatives set out here should improve the ability of the NHS to cope and survive, and they should each be piloted.

 

Dec 2021