City University Cass Business school has worked out what Dr Rant has known for some time. The waiting time targets are a fix. Cass worked out that it was impossible to meet the targets without cheating.
Lets look at some of the tactics Dr Rant is aware of having been deployed:
1. Move the fuckers to another area to make them wait. Call it 'Assessment Unit'. Hey presto. In fact, I'm just waiting for hospitals to rename their A&E departments 'Canteen' so they can bypass the waits alltogether (presumably, this would cause them to breach some other target, like maximum servery wait, or whatever).
2. Don't let the fuckers in. Simply keep seriously ill patients in ambulances outside A&E. The clock only starts when they come through the door. This is particularly fuckwitted because it means that the most seriously ill patients, who are most likely to be in an ambulance, wait longer. Meanwhile the sore toe patients wait less long. And, the ambulances cant reach emergencies because they spend hours queued outside A&E. This is probably the best example of targets making care worse that Dr Rant has ever encountered.
3. Admit the fuckers. Genius! Can't send them home until their blood result comes back? Going to breach the target? Admit them! Then they get to spend more time in hospital, pick up MRSA, and block a beds that, quite frankly, are in short supply.
4. Get extra staff in on the day of the test. Since the unit knows which day they are going to be assessed, they simply buy in expensive locums and bank staff to hit the target on that day. Fucking cheats.
The conversation goes:
DoH: I'm going to ask you next Monday how long your A&E Wait is. If it is more than 4 hours I'm going to fire you. But I'm not going to do any surprise inspections, or check up that you are telling the truth.
Manager: Er....Ok...
Next Monday:
DoH: Hello. How long is your A&E wait.
Manager: It's 3 hours and 45 minutes.
DoH: Excellent. The PM can tell the nation at PMQs how the NHS is having its best year ever.
Passing Patient: But I've been here for 92 hours......[gets bundled off by clipboard wielding managers, who outnumber the clinical staff 2:1].
The managers know they are lying.
The politicians know the managers are lying.
The managers know that the politicians know that the managers are lying.
The politicians know that the managers know that the politicians know that the managers are lying.
Its all one big fucking con.
Tuesday, February 06, 2007
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39 comments:
Nurses in A&E have the lions share of responsibilty for making sure the 4hr target is met.
Do they fiddle discharge times ? well of course they do, I would estimate to the tune of about 5%-8% in our department.
By enlarge doctors don't give a f**k about it, at least not until they have direct responsibilty for explaining to the Chief Exec & Co why they can't tell porkies in the same way as other A&E departments in the region.
In these circumstances the consultant then has to assume the position, just like the rest of his/her minions.
The simple fact is, failure is not an option especially when your Trust is bidding for Foundation status.
Managers, as well as consultants collude in ignoring the 5%, that are discharged via x-ray, or go over the 4hrs by 15-30 mins so they can be seen on the post-take round at the specialty consultants convenience.
In many respects the target is a nonense, of course, for example, if someone is too pissed to know where they are why should we worry about getting them to the obs ward in under 4 hours.
But despite the enormous pressure to cook the books, not to mention the odd madcap scheme, such as little rooms to send patients too pending blood results, A&E services are far better than 10yrs ago, and by a country mile.
Our department now has 4 consultants instead of 2, 24/7 SpR cover, never less that x2 SHOs on the shop floor.
It used to be x1 SHO between 06:00 - 08:00 without SpR back up as well, god help you if there were 2 or more blue calls during this period.
More nurses, and with an established ENP service [yes, I know NPs are shite according to the reservoir dogs].
We are working hard and I think more effectively most of the time, and our patients often thank us for not keeping them waiting for hours on end.
But don't worry, the target will soon be jettisoned as attention switches to some other problematic aspect of the NHS.
We will then be back to the bad old days of interminable waits, inadequate medical and nursing cover, increased casual violence borne out of frustration, that is assuming the A&E department is not one of the 30 or so targeted to be shut down altogether.
the A&E Charge Nurse.
A question, Dr Rant.
In the old days A&E staff grumbled endlessly about the chronic and well documented problems afflicting the service - nothing changed substantially [or ever looked like changing] until the 4hr-target was introduced.
In the absence of a true emergency many patients, including children, could be kept in the waiting room for hours, and all too frequently this is exactly what used to happen.
In fact, not many people realise that one of the unsung jobs of the minors nurse was to extract the roots sprouting from the patients arse after a particularly tortuous wait.
If you object to the stick so much, what is the alternative ?
And more to the point if a reasonable alternative ever actually existed why was it not introduced aeons ago ?
The introduction of the 4hr target simply reflected the fact that A&E epitomised a fundemental NHS flaw - excellent treatment for some while too many others had to take their chance in a lottery.
the A&E Charge Nurse
A&E charge nurse, you make valid points. Dr Rant worked in such units and remembers the long waits.
I'm not opposed to sticks as such. I'm not even opposed to a 4hr waiting target.
What I object to is that the managers are allowed to cheat with impunity.
NuLabour has corrupted the public services with their obsession with 'good news management'.
I do object to 4 hour waits. getting rid of them would stop twats who can't be arsed to wait for a GP appointment to get their verruca sorted out from rocking up at A&E in the knowledge they can have a strop if they're not seen in 3hrs 45mins. And the varruca analogy is not an exaggeration - it actually happened. The olden days (which I didn't experience) don't sound too terrible, as idiots like this could be left to rot for 12 hours in the waiting room and if they could be arsed to wait their patience would be rewarded. Quite a good test of how much you really need to be seen. Admittedly it may have been a wee bit too far the other way, but how about a system where sickies get seen straight away, the unwell-but-stable get seen soon, and the completely-well-but-nothing-on-telly would be left in the waiting room til they got bored and went home. Cynical peut-etre but sounds like a good system to me.
I have worked a night as a medical SHO when there were three very sick patients admitted. There were no ward beds, so they were kept in A and E overnight, where substantial progress was made in their recovery through the hard work and coordinated care of myself, the surgical SHO and the A and E staff (actually being made easier by the patients being located all in the same place, and the same place as other admissions who needed clerking). They could easily have died. Of course, they all breached, and when morning came the A and E sister in charge was severely reprimanded by a senior manager in person for all these breaches. How terrible of us to actually save peoples lives when we could have sent them off half-treated within 4 hours to die in a nice comfortable (and incidentally non-existent) bed in a ward on the other side of the hospital.
Another time I was persuaded to allow a patient to be transferred from A and E to MAU before I had finished clerking them, so that they didn't breach (something I usually resisted). Shortly after transfer, the patient fitted again as he hadn't been given the medication prescribed by the A and E SHO several hours earlier that may have prevented further fitting.
(And all the other patients waiting to be clerked breached as a result.)
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