Austerity in the GP surgery

Curious.

We – my wife and I together – joined our current GP practice because the service was simply so much better than any other we’d known.

The practice is associated with a walk-in centre, which itself provided great support for patients: anyone needing care immediately but not urgently – in other words, patients who were sick or in pain but not obviously suffering from anything potentially life-threatening – could attend the centre and be seen, seven days a week, from early morning into the evening.

A generous service. But not one it pays to cut

That’s a relatively expensive service to provide. There is at large today, throughout the Western world, a view that such expense should be cut back wherever possible. I wrote the other day that it’s often in the little things that we see austerity economics at work, and our GP practice is no exception.

Today, Saturday, I tried to renew a prescription on-line. That didn’t work. I could log in to the system but the buttons thoughtfully provided to select a medication to renew simply didn’t react if I clicked on them (and, before I’m challenged as a computer illiterate, let me assure you that I tried on two machines, using tree different browsers between them).

I then phoned the surgery but was told that, while the walk-in centre was open, the surgery itself was not. Could I ring in again on Monday?

“Yes,” my wife told me, “we’ve had a couple of letters. Funding’s been reduced so that they can’t stay open at weekends any longer.”

Once more, I felt the glacial fingers of austerity gripping my innards.

If the GP practice is facing cutbacks, the walk-in centre won’t be far behind.

While the service it provides seems generous, it’s only those with the narrowest of account-book outlooks, entirely focused on the short term – in other words, Conservatives – who can persuade themselves that such a cutback makes sense. It’s true that shutting down a walk-in centre would save a lot more money than shutting any other kind of practice but, unfortunately, the patients who use it won’t go away. They still feel ill or in pain, so if they can’t find care from a GP, they’ll go to the emergency department of the local hospital instead.

An emergency department is far more expensively equipped than any GP surgery. I’m not just talking about physical equipment, much of which is indeed costly: for instance, devices to provide a view of what’s happening inside a human body, whether by ultrasound, radiology, or some of the more powerful and sophisticated techniques now available such as CT or MRI scanning. However, even that fades into insignificance compared to cost of staff: medical and nursing staff on a wide hierarchical range, professional support such as pharmacists and various types of therapists, and even administrative staff.

The result is that while it may cost £50 to see a GP, it can cost £124 on average to attend an emergency department.

Cutting back on GP care is, therefore, a false economy.

There’s nothing unusual in that consequence of Conservative healthcare policy. All over England, hospitals are spending a fortune on agency or bank staff (“bank” is in effect overtime: existing staff doing additional hours on a far more expensive, hourly-paid basis). Why are they spending so much? Because they’re being denied the funds to take on more permanent staff, though that would be cheaper.

Of course, the false economy of shutting the walk-in centre would turn into a real one, if the patients denied treatment were unable to attend an emergency department instead. But for that to happen, our local hospital would have to close, or be replaced by a private one which only treated patients who could pay the full, economic cost of the care it provided.

I suspect a lot of people at the top of the Conservative Party would be perfectly easy about that happening.

However, I wonder if all their voters, further down the income range, would agree with them…

Avoiding the avoidable: the problem of delayed discharges

So far I’ve mostly talked about avoiding the avoidable in hospital expense only at the start, the admission stage, of a hospital stay. But the problem arises at the other end too, when a patient has to stay on because the discharge process is delayed. 

There are two main reasons why this might happen.

OK, so why can’t I just go home?

The more obvious one is that the discharge has not been properly prepared. Tests need to be carried out to confirm that the patient is fit to go home, but the results haven’t been received – or perhaps the tests haven’t even been ordered. Possibly the patient needs to take medications home and the necessary prescription hasn’t been sent through to the hospital pharmacy. Or, even more simply, the discharge needs the approval of a doctor who simply isn’t available, called away to an urgent conference which perhaps, and entirely coincidentally, is taking place next door to a prestigious golf course.

This kind of problem occurs everywhere. Recently I read a 2014 study of two hospitals in Brazil. It found that in one of the hospitals, delayed discharged represented a 23% extra occupancy rate, a figure that climbed to 28% in the other. That means a massive proportion, around a quarter, of the beds in those hospitals were occupied at any one time by people who should already have left.

The other main reason for a delayed discharge is particularly familiar in a nation such as England. Patients can’t leave because there’s nowhere for them to go where they will receive the ongoing care they need. This is particularly acute for older people who may be living alone with no one available to act as carer. They can only be discharged once there is a social worker or community nurse available to help them, or perhaps a bed in a care home.

Delayed discharges generate two problems. First of all, it’s bad for the patients: people generally recover better in their own beds than in hospital and, in any case, simply by staying on patients are exposing themselves to unnecessary risk, if only of infection from other patients around them.

Secondly, the delayed discharge is bad news financially. Acute hospital care is the most expensive care and, even though costs will be lower towards the end of a stay by which time the patient requires less treatment, the mere fact of occupying a bed is expensive. That’s without taking account of the impact on other patients who might have benefited from being admitted to a bed blocked in this way.

A recent study (February 2016) for the NHS in England by a team headed by Lord Carter of Coles, Operational productivity and performance in English NHS acute hospitals: Unwarranted variations, put a figure on the impact of delaying discharges: “the cost of these delays to NHS providers could be around £900m per year.”

That’s close to 2% of the total expenditure on acute care.

How do we fix these problems?

Both require management action, naturally. For instance, my wife worked until two or three years ago in the Discharge Planning team of our local hospital. Here, nurses, social workers and hospital staff worked out of a single suite of offices, preparing the plan to discharge a patient from the moment he or she was admitted. That meant that the agencies involved in post-hospital care had the greatest possible notice that their services would be needed. They could, therefore, assign staff or find suitable accommodation, at least as far resources allowed, in the most favourable possible conditions, rather than in a rush at the end.

Equally, steps can be taken in plenty of time to ensure that all necessary processes are carried out, the appropriate tests or medications ordered, and the paperwork prepared for someone to sign who will be around at the right time.

Computer systems can help, of course. The kind of pathways management software I’ve been talking about in this series can be used by hospital staff as it can by people in primary care. It can issue alerts not just to physicians but to nurses and care assistants: “for this patient to be discharged tomorrow morning, you have to request this test today,” for instance.

When it comes to helping with groups like my wife’s former colleagues, what’s needed is ways to improve collaborative working between different systems. Social work management software needs to interwork with nurse management and general hospital systems. Fortunately, none of that is impossible and over the last few years, great strides have been taken towards making it happen.

What that means is that avoiding the avoidable can now be tackled at both ends of a hospital stay: discharge, with its own specific problems, as well as admission.

Not so much a death wish as a death data wish

A terribly exciting development at work: I may soon be able to count hospital deaths. Properly.

End point. And the starting point for some interesting work.

This fulfils a bit of a longstanding ambition. For years, I’ve watched people who really ought to know better abusing mortality statistics to assess the quality of hospitals. This hospital, they tell us, has a far higher death rate than that one, so it must be a lot worse. When you object, ‘but that hospital is basically a baby factory, delivering thousands of children a year, while the other one is a major cardiac centre’, they sometimes come up with ‘risk-adjusted’ figures, which sounds great except that no-one’s ever proved that risk adjustment methodologies actually adjust for risk.

At least the ones who make adjustments are trying to be conscientious. I know of one consultant who submitted a report to a hospital showing that a cardiac surgeon had a one in three death rate for a particular procedure, which was frighteningly high compared to national values. It turned out that the surgeon had carried out just three of those operations in a year and one patient had died. So it was a meaningless statistic and the report demonstrated nothing but the incompetence of the consultant.

Besides, in doing these studies, people generally base themselves on in-hospital mortality. You may know the story of the man walking home one night and finding another on his hands and knees underneath a lamppost.

‘What’s the problem?’ asks the first man.

‘I’ve lost a contact lens and I’m looking for it,’ replies the second.

‘OK , let me help.’

After twenty minutes of fruitless searching, the first man says, ‘are you sure you lost the contact lens here?’

‘Oh no,’ says the second, ‘it was nowhere near here. But this is the only place with any light.’

In-hospital mortality is like that. Hospitals record deaths meticulously, so the figures are there. But that doesn’t mean that they’re a good place to start looking for answers.

First of all, they're a lousy indicator for something like Obstetrics. In the developed world, deaths in childbirth are now incredibly rare (though there are indications of a worrying tick upwards in the United States) so the numbers don’t tell you much. On the other hand, in palliative care, mortality is extremely high, but that’s the nature of the discipline, so again the rates aren't particularly helpful.

Mortality is only useful when you apply it to areas where there is a relatively high risk of death, but specifically of avoidable death. Stroke care. Cardiology. Various types of organ failure. That kind of thing.

But also it’s no good using just in-hospital deaths. Cases get transferred between hospitals. A general hospital might move a particularly ill patient to the specialist centre up the road. If the patient dies, which hospital should be concerned, the first or the second?

Incidentally, it’s a curious peculiarity in England at least, that if the patient dies in the ambulance between the two hospitals, neither gets the death assigned to it.

Again, some hospitals keep their lengths of stay low. This is a good thing from the point of view of financial efficiency and may even be good for patient care: hospitals are dangerous places (full of sick people) and the sooner you get home the less likely you are to pick up an infection. But, if a patient is discharged quickly and then dies at home, that death won’t be recorded against the hospital either.

What has got me enthusiastic recently is that a body in the NHS, the Information Centre, has for two or three years been linking English hospital data with general records of deaths held by the Office of National Statistics. This means that they can now make available information about patients who died following hospital treatment, whether or not the death took place inside the hospital.

So we can get a clear idea of how many people are surviving or dying after hospital treatment for a stroke or an aneurysm, even though the death took place after the hospital discharged the patient.

I'm about to apply to be given access to the information. That may give me some better ways of understanding how well individual hospitals are delivering specific types of care for specific types of condition.

It’s a bit sad to admit, but that’s the kind of thing that makes me excited about the work I do.