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policy
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Tell us what you think our hospitals should be like in ten years’ time. What are the big changes we need to make in the way we organise, staff and deliver hospital services to ensure that all patients receive high quality care?

See our work on the Future Hospital

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Anonymous
FHC - Generalism Vs Specialty / Primary Vs Secondary Care
The NHS non-elective system is intrinsically designed and delivers on the basis of generalists (eg GPs, ED teams, latterly Acute Medical Units) acting as gatekeepers to specialist care. Increasingly many patients especially to non-elective care will not come with single organ, clearly defined clinical and social problems. Hence we need to fortify this gatekeeper role better, so that when (as early as possible) a specialist problem is identified the specialist teams are well equipped to take and run with 'the ball'. Flow of patients within non-elective services will improve, outcomes too. If we collectively approach with the right attitude and culture of teamwork and continuous improvement, patient experience will improve too (linked, but not in a linear fashion, to process and outcomes). The key has to be good clinical leadership and communication, handovers rather than hand-offs. There must be a level playing field for everyone to share the strengths and weaknesses of our system in a proportionate and sustainable way. It is vital that we make the right thing for the patient the easier thing for clinical teams to do - how often to we impose barriers such as complex and bureaucratic referral forms or nebulous and poorly accountable clinical pathways as a disincentive to making the right thing happen today?
Anonymous
Future Hospitals must have adequate liaison mental health
A significant proportion of hospital patients will require care for mental health problems. Liaison psychiatry teams are best placed to provide this and they can also play a key role in training non mental health professionals at recognising and responding to some of the more straightforward cases. Liaison teams are also excellent at dealing with challenging behaviour, alcohol problems and medically unexplained symptoms. Where they exist, liaison psychiatry services are highly valued by acute colleagues and they save money by reducing length of stay, especially for older people. Every hospital needs a liaison psychiatry team -it's a win-win situation! The reports below illustrate some of the benefits of liaison psychiatry. http://www.centreformentalhealth.org.uk/pdfs/liaison_psychiatry_in_the_m... http://www.centreformentalhealth.org.uk/pdfs/economic_evaluation.pdf
Anonymous
Properly integrated / communicated care
The boundary between secondary and primary care is mostly artifical, a large amount of healthcare can be done in either setting. I agree with Dr Houghton that GPs going into hospitals and specialists in the community are longstanding arrangements which could be built upon much further to good effect. Communication is paramount in every direction - within the hospital, to patient (and carer), into the community team (including mental health and social care) - but there needs to be a balance since a twelve page discharge summary can be almost as unhelpful as not receiving one at all. A fully-integrated record / encrypted on-line record / patient-held records are possibilities (and ideally shouldn't take 10 years). We also need to think carefully about what we should not be doing within the healthcare system - for reasons of not doing harm, not creating health worry, not incentivising "activity" within the system. Patient demand is rising - sometimes with very legitimate reasons - but sometimes not. We should aim for "high value" [Porter M., N Engl J Med 2010; 363:2477-2481] interventions that are clinically well evidenced, safe and also cost-effective. Outcomes should be those that matter to patients (often relating to quality rather than quantity of life) within the bounds of a puiblicly-funded healthcare system. Dr Christopher Cooper, GP, London
Anonymous
care home admissions
perhaps I have missed it, but I see no mention of admissions from care homes. Over the past 2 decades or so the number of very frail and complex patients in nursing homes has increased. This is as a result of decreased hospital beds and increased longevity as well as other less well defined factors. There is often an inability in the care home sector to manage various conditions including the dying patient (with poor anticipatory care planning), simple fluid replacement and use of I/V antibiotics so that such patients are admitted as emergencies. This sector needs support to do this better. On the other side I feel there is also a lack of appreciation in the secondary care section about the type of patient who can be managed at home, including in care homes. Old age medicine has moved away from doing home visits and I feel this has made many specialists more risk averse. lack of continuity of care also contributes to this, it is easier to take decisions to discharge when some responsibility for ongoing care lies with the same team. It is not at all unusual to see patients with recurring admissions admitted under the care of several different physicians. If we are to change the hospital process, and we must, then we have to look at the whole system of care from primary care, including out of hours care, to secondary care, and to social care including in the private sector, and in particular where these disparate systems interract.
Dr PJK Pearson FRCP
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Future Hospital - lacking ambition?
I remain concerned about the way the project is developing - and I fear the RCP may wind up with a white elephant that does not really set the standard for the next 20-30 years, as it should.

(As an aside, and to counter comments from a senior RCP official: I think we should retain the WTD as is because it is safer for patients.)

To deal with some of the questions asked:

"1. Is the analysis described in Hospitals on the edge?accurate? (See ‘Introduction’ of the report for an overview)"
--> Yes, I think it is (at least the broad brushstrokes) – the current pressures on the acute medical environment are considerable and rising.
"2. What are the key obstacles to service change? How can these be overcome?"
--> Several:
* Alas, not infrequently a focus on money to the exclusion of all else – in particular the delivery of safe patient care.
* Lack of encouragement of training for consultants and a failure to make time for training for junior staff. → So: Listen to – and act on – recommendations from the shop floor, as quality improvement projects supported by a mentor, so that a decision can be made based on evidence.
* Lack of continuity of care; multiple hand-offs. → More complex: relates to...
* Acute-and-generalists thinking that they can do all branches of medical practice, leading to sub-standard care. → The time may have come to abolish 'general medicine' and 'acute medicine' because all that does is perpetuate the myths that all general physicians can do everything and that a patient will receive equally good (say, respiratory) care under a respiratory physician or a gastroenterologist: nonsense. (See also Q4-C (Expert General Physicians) below.)

4. What are you views regarding the themes identified by the Future Hospital Commission described in What next for hospital services? (See sections three and four of the paper)"
--> OK. I think section 3 looks reasonable. Section 4 is more problematic:
"A. Fewer moves - After an initial assessment, patients should not move again unless there are exceptional circumstances."
--> Agree: this will help significantly: I suggest the initial assessment is done in the Emergency Department (only) and the patient is then either discharged with appropriate (primary or secondary care) follow-up or is admitted straight to the right speciality (24/7).
"B. Single consultant-led team
"a. A single consultant-led team should be responsible for a patient’s care throughout their stay in hospital. The consultant-led team involved in care on day of admission, should deliver care the following day. Rotas for medical teams should be designed so that ‘on-call’ days are followed by scheduled days for follow up."

--> Yes, I think that would help.
"b. Each ward should have a named consultant responsible for liaising with the ward manager on basic standards of care for all patients."
--> No: each consultant-led team should be based on a named ward, with patients only there, but with (often) 30+ patients on a ward, there may be a need for more than one medical team per ward.
"c. Patients with multiple conditions on non-medical wards (eg surgical wards) should be cared for by a single medical team on an ongoing basis."
--> Disagree profoundly: this institutionalises a systems failure that can compromise patient care. I do not think there should be medical outliers for any reason short of a true emergency (a pandemic, say; winter is not an emergency, it's a predictable time of year!!)

And for the more controversial bit:
"C. Expert general physicians
"a. Physicians with specialist expertise in general medicine (including acute, general internal medicine (GIM) and elderly care physicians) should provide continuing care to patients, unless specialist care in a designated specialist ward is required."

--> No: there are no such things as “expert general physicians”. I have seen enough bad respiratory medicine done by well-intentioned consultants who think they know about the management of pleural disease and COPD to a) keep me humble about my understanding of other non-respiratory disease; and b) make me more & more convinced that the concept of “general medicine” is past its 'sell by' date. The introduction of Medical Assessment Units owes more to the need to 'beat' the four hour target in EDs than to a desire to truly improve the standard of care for medical patients: they are (generally) a fudging unit rather than a useful assessment unit. They also do not encourage speciality-specific ambulatory care (facilitated by good community care) – not least because that crosses boundaries: excellent for the patient (esp. COPD), but not so easy for the finance managers because they look at it as 'losing money'. I remember a RCP "Acute Medicine" study day a couple of years ago: the cardiologist's main theme was 'don't admit to MAU but go straight to the cardiologist'; the stroke physician, nephrologist and hepatologist were all similarly clear about their own specialities; by the time the respiratory physician got up, he grinned sheepishly - before making the same comment for respiratory patients. I think we need to be brave and consign gen./acute medicine to its historical place.
"b. Advances in treatment and care brought about by increased specialism in medicine should be protected. At the same time, we must ensure general medicine is an attractive option for to doctors at all career stages."
--> See above: I think 'general medicine' needs a profound re-think. Start with: what will be best for each patient coming through the door (backed up with: who would I want to see if I were admitted with a 'x; problem?) I think the 'general physicians' should be the ones in ED who can refer to the appropriate speciality.
"c. Training in general medicine should be the norm for trainee doctors."
--> So many things with this... First: 'trainee doctors' are medical students; the ones who we have on our teams are fully qualified 'junior doctors' whom we are meant to be training. General medicine: needs re-definition, as above.
“Should be the norm” for medical students: yes, certainly, they need a good grounding in medicine (and surgery and general practice and other specialities) before they graduate. “Should be the norm” for junior doctors: harder – not least because most are not in medical jobs and do not want to be physicians. “Should be the norm” for core medical trainees: one would certainly hope so, yes! For those beyond CMT: again, tricky; this depends on how we want to re-define general medicine. The present model is unsustainable.

... and that's enough for now!

Best wishes Philip
policy
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Joined: 07/07/2011
Thank you Philip for your
Thank you Philip for your detailed comments regarding the work of the Future Hospital Commission. As stated in the ‘emerging themes’ paper, we are not at the stage of making recommendations but are seeking to generate discussion on key issues that will then inform the final conclusions of the Commission, so your comments are very timely. Discussion around the role/s of specialist expertise in general medicine have arisen out of recognition that there are a growing number of patients with comorbidities that do not fit neatly into a single specialty ward, which can impact on a patient’s continuity of care. At the same time, we recognise that there are a number of high quality specialist pathways (such as for stroke) that are working well and should continue to be supported. It would be untrue and unhelpful to suggest that a patient with COPD would as well looked after by a gastroenterologist as by a respiratory physician, however we know that many patients with COPD also have heart failure that worsens with their COPD exacerbation. One key feature of the new generalist is to ensure that the patient receives the best quality of care for all their conditions as for the one that the team whose ward they are on happen to be specially trained in and this will mean co-ordinating expertise. We also recognise that the population with long term conditions is growing and that the specialists in these areas (lets take COPD again) are needed to advise in the community as well as during an acute admission. One possibility therefore that we are considering is that a patient is best served by an enlightened generalist during an acute exacerbation with input from all necessary speciality teams that know them and will be seeing them prior to and following their admission. Our staffing resources are limited and using the workforce most efficiently is a challenge and the current work of the commission wants to free up specialists to work more in ambulatory care services, in admission avoidance schemes, in integrated community care thus reducing the need for some patients to attend the acute hospital at all. However these ideas are still very much in development, and your core approach of considering “what will be best for each patient coming through the door?” is an important principle for our work. The discussion you raise around appropriate training is extremely important. There is very little true “general medical” training going on today, and this may be one reason why patients don’t get such good care when they are on a ward that doesn’t accord with their predominant disease. We are seriously reviewing how we best equip tomorrows consultants from medical school with the skills to care for patients with multi-morbidity, poly pharmacy and excessive exposure to social harms. For any specialist to do this they will need to have a good working up to date knowledge of other medical disciplines and perhaps an ongoing role in acute medicine is a way to achieve this.
policy
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Joined: 07/07/2011
Seeking feedback on emerging themes
Thank you everyone for your comments on our work on the Future Hospital, which have been passed on to the various clinicians leading the different areas of work . As the work is progressing we have identified a number of key areas that we are keen to receive further feedback on. These include delivering a seven-day health service; reducing the number of times patients are moved within the hospital; ensuring a single consultant-led team is responsible for a patient’s care throughout their stay in hospital; expert general physicians and the interaction with specialised care; designing care for patients with dementia and improving the transfer of care. We have developed a short briefing outlining these themes, which can be found here: http://www.rcplondon.ac.uk/resources/emerging-themes-future-hospital-com...
Dr H McIntyre MD ...
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Joined: 18/10/2012
Clinical Teams and the quality of care
The imminent publication of the twice-delayed Francis report, which is widely expected to comment upon many levels of care supervision, will place quality of care at the centre of discussion about healthcare. Whilst much of the report is expected to focus on, and be critical of, external scrutiny and inspection, recent anticipatory responses from both the Kings Fund and the National Quality Board highlight the central role of the clinical teams. The latter report specifically identifies the remit of the Care Quality Commission in securing 'essential levels of quality and safety' with improvement in the quality of care driven by Quality Standards defining aspirational but achievable indicators of high quality care to support 'the whole system in striving for excellence'. These statements need to be considered in the context of the White Paper which stated 'unless we are clear about what we mean by quality and are able to measure it, there can be no meaningful accountability' Taking a step back, at it's heart high quality care is about improving the health of people with need. Quality initiatives can define this transaction but it is the clinical teams that deliver the care that engenders the improvement for the individual. To embrace quality is to embrace improving health. The quality of care will be under increasing scrutiny in the NHS. The successful clinical team of the 'future' will be the one that, with and on behalf of the individual, owns the quality agenda. The Commission is asked to place clinically-led quality improvement at the heart of its considerations.
Dr MP Houghton FRCP
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Joined: 11/04/2011
Future Hospital - Generalists. Role of General Practice
If there was no primary/ secondary care barrier and interested GPs did sessions in hospital would this not be a huge step forward? They would need training and appropriate assessment but there would be interest both from individuals and I'm certain the RCGP. In such a system these doctors could not only deal with the multiple morbidity (this is our bread and butter) but ideally give general medical opinions and pass to the appropriate specialty. Such a doctor would understand community resources and share problems with primary care colleagues. Both the RCGP and RCP are publishing widely on generalists. With the advent of four year GP training (and a smattering of old warhorses like myself around) is it not time to pool resources?
Dr AJ Hutchison M...
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Joined: 13/06/2011
Future Hospital
The push towards a 'consultant led service' is an appropriate way forward, but only if enough consultants are employed. The separation of junior doctors (employed by the Deaneries) from the Hospital Trusts where they work is understandable from a training point of view, but not from a strategic point of view. If my unit held the juniors contracts we would have replaced several of them with consultant posts in order to increase consultant numbers and reduce trainee numbers to a point where there was a reasonable chance that they would be able to find jobs. As things stand at present we are unable to balance the junior doctor numbers or the consultant numbers because the Deanery will not relinquish the salaries. I visited a unit in Stockholm some years ago, which serves a population half the size of ours. It has more than twice as many consultants and less than half as many juniors - THAT is a consultant led service, and it's better for junior training, and we should be aiming for something similar.
Anonymous
Creating the future hospital
I am submitting this comment from the perspective of an ex-Social Worker, and current Psychology postgraduate student. For many years, I was employed in Mental Health Social Services, before moving to a job within a Hospital Discharge Team. During the latter role, I saw just how poor care could be for patients; although, I have to admit that Mental Health Services fares little better, given that it is often viewed as a "Cinderella service" in its own right! How, in this day and age, can care for some STILL be so inadequate? How can "Cinderella services" still exist? When I trained as a healthcare practitioner, it was with a view towards providing holistic, patient-centred care. I wanted genuinely (and naiiveley, or so it seems) to do the best for patients - to help them to recover, to provide them with information about their treatment, and management of their condition, to provide practical support, and emotional support, to educate them as to how they could become more adept at spotting their own symptoms, relapse indicators, and so forth. I truly believed in multidisciplinary team work, and in coordinating and cooperating with colleagues from other disciplines in such a way as to provide the best possible care for patients. Oh, foolish me! With hindsight, I now realise that the way in which I had wished to practice was just a dream - a fallacy. The reality of daily work was NOTHING like this! The question of what can be done to create a good hospital of the future is a pressing one. It is also, sadly, nigh impossible to answer. There is perhaps so much now wrong with our ailing healthcare system that, I fear, to ask this question now is simply too little, too late. Where to begin? I can but highlight a few of the issues that DESPERATELY need to be addressed before we can even begin to talk of the notion of a "good" hospital... here are but a sample of a wide range of problems afflicting the delivery of care: 1. Governmental cuts to funding - goes without saying that these will have HUGE implications. True, we are in the midst of a recession. But, why is it that the Public Sector (who, incidentally did NOTHING to cause the recession) must pay? We are talking, here, about VITAL services, upon which the whole of society is reliant. Education, healthcare, policing, social care... is there anyone out there prepared to suggest that we can do without? Then why are such provisions taken so terribly for granted? Despite all the rhetoric about nurses and doctors as "angels", about firemen and ambulance crews as "lifesavers", about police and social workers as "safeguarding the community"; the truth is, that much of the work done by those employed within the Public Sector goes unrecognised, unacknowledged and vastly under-rewarded. Average levels of Public Sector pay have already failed to keep up with the growing cost of living. Pay rises do not match rises in inflation. many Public Sector workers struggle to get on the "housing ladder" and struggle to make ends meet. Yet, now, the Government is asking for cuts in pensions to be sanctioned. Budgetary cuts, too, are being given the go-ahead, despite the fact that these will clearly mean a reduction in service provision, or at the very least, existing services being harder pressed to come in "on budget". And we all know what that leads to... more stringent admissions criteria for hospitals, more stringent acceptance criteria for community care, longer surgical waiting lists as procedures cannot be funded, fewer hospital beds, short staffing... 2. The existence of "Cinderella services" - why, oh why, in this day and age? Yes, I understand that, historically, some services have received less publicity, and less funding than others. Yes, I understand that this may have had a knock-on effect. But, still, when one begins to analyse the reasons behind this, one can only see prejudice and ignorance. Traditionally, "Cinderella services" have been those which are neither glamorous, nor high profile. They are not appealing to the public eye. They serve individuals within the community who generally comprise some of the most stigmatised and deprived groups... in the main, "Cinderella services" comprise mental health care, care of the elderly, care for those with learning difficulties, and a host of other socially "unacceptable" services such as continence care, gynaecology, etc. Historically, those deemed "insane", or "infirm", or "unable to work", or "slow", "incapable"... oh, yes, as a society we are VERY adept at labelling and thus stigmatising some individuals... have also been marginalised, and thus deemed worthless and undeserving, as well. To compound the problem, the Government now wishes to try to run the health service as a money-making business. Therefore, those holding the power are businessmen, and media moguls, NOT individuals with a background IN healthcare. Only those initiatives that are high profile, and are likely to bring in profits, are considered worthy of being well organised, resourced and funded. And, when I say high profile, what I sadly mean is "media friendly". After all, who would "Joe Public" rather take pity on, who would "Joe Public" rather see funded? The gibbering psychiatric patient, a schizophrenic potential axe-murderer? Or the poor, pale, sickly but cute child, with the big blue eyes, and the parent crying their eyes out, for fear their little darling will succumb to Leukaemia? Yes, I may have taken liberties with poetic licence; but, alas, this IS how the media portrays health. Some conditions still attract revulsion and stigma, fear and hatred. How many newspaper articles must we read, telling us about psychotic killers, alcoholics, drug addicts? When will we EVER see a positive image of learning disability? Can the public EVER be encouraged to talk openly and frankly about such things as stress incontinence, or alzheimers disease in the elderly? Whilst such blatant ignorance and hypocrisy still persist, NOTHING will change. "Cinderella services" will remain, under funded, under resourced, under privileged. Our society liberally encourages us to turn a blind eye to matters we would rather not think, or speak, about. And whilst this is the case, stigma, labelling and prejudice will prevail. 3. "Divide and conquer" - imagine a unified healthcare service. A unified Public Sector. Imagine the POWER this would have! Power to change, power to make improvements, power to demand better funding, better resources, better pay. Imagine just what a THREAT that would be to the Government, who would then have to PROVIDE all of these things, as opposed to merely talking about them! At present, health provision comes through a variety of services, none of which seem able to work comfortably, or effectively, side-by-side. Holistic care is a goal to be aspired to, as is effective multidisciplinary team working. However, it would seem that we are far from attaining this goal at present. Now, I am not attempting to lay the blame with individual practitioners (though there ARE some out there who ARE clearly at fault). The truth is that there are several factors contributing to a sense of "division" within care services. Firstly, Health and Social Services have historically been separate entities, with separate funding, and separate resources. They also have separate training, and hugely divergent notions as to models of care. Consequently, in a multidisciplinary environment, do we follow the "medical model of care" or the "social model of care"? Do we use the "medical" or "social" model of disability? The adoption of one or the other has implications for diagnosis and treatment. On a smaller scale, why the divisions between different disciplines? Sometimes, I used to get the impression that one discipline was not even sure of the role of another! Might it not be advantageous for ALL medical practitioners to share a common foundation year of training? That way, the Doctor would understand and value the role of the Social Worker, the Physiotherapist, the Nurse, and vice-versa. To provide holistic, continuous care, ALL practitioners, no matter their discipline, need to have a basic working understanding of the role and remit of their colleagues. They also need to view them as valuable resources, as practitioners with their own special insight into a patient's condition and care. Multidisciplinary team work should be just that - TEAM work. Staff should NOT have to feel they are competing for time, money, resources, training. They should NOT feel that a hierarchy of superiority exists where one practitioner must defer to another. At the end of the day, each and every person involved in a patient's care has a valuable role to play, and can provide valuable time, and valuable knowledge. Let us NOT forget this. 4. Lack of broad spectrum knowledge - again, this derives from a multiplicity of factors. One is mentioned above, poor training. Healthcare practitioners need to have a good understanding both of their own roles and remit, and of those of others. They need to be able to understand and appreciate the need for timely and appropriate specialist referrals. They need to be able to understand and appreciate the social implications of medical treatment, and hence, the need for cooperation and coordination with social care. Those who work within the hospital in-patient setting need to be able to understand and appreciate not just what constitutes good care within this setting, but also the need for good aftercare within the community. They must therefore be able to refer to appropriate services in a timely manner, and liaise effectively with them. Care does NOT just comprise the hospital setting, and good care does NOT stop at discharge. Post discharge care should follow seamlessly on from hospital care. All who are involved in a patient's care should know their own specific purpose, and should also know what others are there to do. Each and every one involved should be aware of the contributions of others, should contribute to care planning, and should be able to contact and liaise with each other easily and effectively. This should be clearly communicated to patients, families and carers (thus putting them at their ease). Too many so-called "flagship" trusts have become specialised in one area of care only, such as cardio-thoracic care, cancer care, or some other high-profile "money spinner". They lack a good generalised knowledge, and therefore struggle to cope adequately on a day to day basis with the wide range of issues that patients on the whole present with. It is NOT acceptable to sacrifice good generalised care for the sake of funding and resourcing specialist centres. Patients do NOT just suffer from a limited range of conditions, and a hospital must therefore be capable of providing excellent treatment for ALL, not just for a limited number of condition- or symptom-specific patients. 5. Lack of specialist knowledge - this probably seems a little ironic, given that I've just complained about a lack of generalised knowledge... but, it's also relevant. What I wish to highlight is the fact that there are a huge number of medical conditions that go undetected for many years. This may be due to under-reporting, misdiagnosis, or lack of diagnosis. Yet, the effect is the same - they are missed! The patient is not accurately diagnosed in a timely fashion, and therefore does not receive appropriate support and treatment. In addition, the patient may be subjected to many years of futile tests and inappropriate procedures, may be misdiagnosed and given inaccurate treatment; or, conversely, may simply be ignored, labelled a hypochondriac, or told that their symptoms are imaginary (suggesting, even, a misdiagnosis of psychiatric problems). In the main, I would suggest that this is happening due to a lack of specialist knowledge amongst practitioners. It is also due to a lack of creativity, inability to "think outside the box", and to a culture that seems always to dictate that the practitioner plumps for the easiest and most obvious option as a diagnosis. We seem to have forgotten the concept of DIFFERENTIAL DIAGNOSES. Surely, when assessing a patient, ALL options must be considered... for example, abdominal pain, bloating and upset stomach are NOT always symptoms of Irritabe Bowel Syndrome (which appears most usually diagnosed). They can also accompany a host of other disorders, including several which are not even of a gastro-intestinal nature, such as Endometriosis, kidney problems, forms of poisoning (including drug related), cancer... Practitioners need to be aware of the fact that, where a specialism is chosen and pursued as a career, in-depth knowledge of the subject is required. There are a vast number of conditions which are not adequately recognised, researched or understood at present; and this clearly has a detrimental affect upon care and treatment. Endometriosis (from which I suffer myself), Adenomyosis, Polycystic Ovaries, M.E. (also known as Chronic Fatigue or Fibromyalgia), causes of chronic Sinus and Respiratory infections, some blood disorders (e.g. Thalassaemia, types of hereditary Anaemia), some cancers (e.g. Leiomysarcoma) and some digestive disorders (e.g. Caeliac Disease) - ALL are very good examples of conditions which are under-, or misdiagnosed due to lack of specialist awareness. 6. Staffing problems - there are a whole host of these in evidence, from short-staffing, through poor staff morale and high turnover, to badly-trained or inadequately trained staff, and downright dangerous staff. Clearly, the first issues are related. A lack of available funding, and cutbacks, allegedly due to the recession have lead to short-staffing. This,in turn, leads to higher workloads for existing staff, stress and poor morale. many staff may risk "burnout" and thus leave in search of better opportunities. Less well-funded facilities therefore always lose out to those that are better resourced, better funded and can offer more opportunities in terms of vacancies, training, job satisfaction and promotion. It is clear, also, that those facilities which are not well-funded will also struggle in terms of affording and offering adequate training to staff. Many may have to get by on the bare minimum, undertaking only those courses that are necessary to ensure they retain professional registration. Consequently, they may feel stifled, unsure of their skills and let down by their employers. Again, this lowers morale and leads to increased turnover of staff. The issue of dangerous practitioners sadly does exist, but is probably harder to tackle, as the reasons for the existence of such practitioners are often hidden. Possibly, such staff continue to practice because others are scared to comment upon their poor practice, and turn a blind eye, fearing recrimination should they complain. It is well known that "Whistleblowing" is NOT encouraged or accepted amongst the healthcare professions. Many excellent practitioners have been bullied out of their jobs, harassed and ostracised simply for blowing the whistle on bad practice. Cases have even gone to Tribunal (Chowdhury v Ealing Hospital NHS Trust), hit the headlines (e.g. the case of CQC director Kay Sheldon, the case of scottish Nurse Rab Williams), and have lead to the Government being forced to consider greater protection for "Whistleblowers". In the meantime, you might like to consider how such TERRIBLE and LETHAL staff as Beverly Allitt and Harold Shipman went unnoticed, or at least unreported, for so long. It does NOT bear thinking about! 7. Lack of encouragement of good practice - where are the rewards for this in a culture that, as I have mentioned above, turns a blind eye to the likes of Harold Shipman and Beverly Allitt? If staff are not encouraged to complain about bad practice, and are, instead, subjected to a regime of threats and fear of ostracism, or worse, dismissal on false charges, then how can practice ever be improved? Good practice stems first and foremost from a desire for good practice. It also depends upon good training, good staff morale, good protocols and following of procedures, good communication, good accountability... 8. Better infrastructure - yes, some hospitals are old and outdated. They lack space, or have only a limited number of wards or operating theatres. Time to spend on the Public Sector, NOT cut funding! We need buildings that are designed specifically with good patient care in mind. Hospitals that have adequate parking for staff and visitors. Hospitals that are accessible easily to disabled people. Hospitals with enough operating theatres, and wards. Hospitals that are spacious, bright, clean... that provide a pleasant and hygienic environment in which to receive treatment and recuperate. Things such as decor must be well thought out - children's wards should be cheerful, and provide facilities for children to play and to learn, as, were they to be at home, this is what they would be doing. Maternity wards should be comfortable, and think about the needs of pregnant and nursing mothers. Ward bathrooms should take account of the needs of disabled users. Planning and design of facilities should also take account of ethnioc minority users - for example, Asian women may not appreciate mixed wards. Signs and literature should be available in a variety of languages, and interpreters should be accessible. Meals should be carefully thought out, both to provide good nutrition, and also a pleasant experience in terms of choice and flavour. Vegetarians and others with special dietary needs should be catered for, as again should ethnic minorities. Staff, too, should benefit from hospitals that are "user friendly". They need to have wards which mean that ALL patients are visible to the nursing staff, and are easily accessible in emergencies. Equipment such as hoists needs to be easy to use, and readily available... I could go on... 9. Zero tolerance on aggressive or disorderly behaviour - this applies both to patients, and to staff. Quite simply, it is in the interests of good patient care that staff and patients conduct themselves in a polite and appropriate manner. Staff should not be subjected, as they may be at present, to shouting, swearing , abusive language, threats and violence by patients. Drunkenness, drug misuse, mental illness, learning difficulties, shock, reactions to medication - ALL may be cited a reasons for "patient outbursts", but it is still better NOT to have such things happen at all. Patients should not be dismissed, ignored, overlooked, sidelined, treated with disrespect or contempt, treated as a nuisance, belittled, talked over the top of, shouted at, threatened or coerced. Yet these things happen. Staff often cite such things as being busy, being tired, stress, being overworked, short-staffing... as reasons why they do not always respond to patients in an appropriate manner. Again, it is still better NOT to have such things happen at all. Disorderly behaviour, by patients, or by staff, can lead only to complaints. Complaints lead only to dissatisfaction. The outcome of such can have numerous negative effects - staff leave in search of better jobs, patients refuse to use a hospital where they hear staff are "rude", staff work in fear, patients are afraid to communicate their needs. Again, much of this is about communication, and a need for good staff training. Analysis of past incidents, and what contributed to them may help us to learn about new ways in which we can deal with the subject of aggressive and disorderly behaviour. But, at its heart, it is about creating a culture of mutual respect, trust and cooperation. There are numerous other factors that I could have mentioned, but time is limited, and this comment is already long! Hospitals and healthcare are about providing a vital service for people in need; people who are sick, and often vulnerable. The staff who provide care should be able to do so in an environment that is conducive to their providing the best possible care. They should feel rewarded for doing an important job. Patients should feel they are important, that they are cared for in a system that listens to their needs and works towards providing the best possible care. patients and practitioners should be working hand in hand to create the future hospital for themselves.
Dr JW Dean DM FRCP
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Joined: 28/02/2012
The drive to Generalism
Although there is much to commend in the Future Hospital Commission's work so far, I feel that it's push towards increasing generalism is misguided. This idea is championed by Professor Tim Evans who calls himself a generalist but who works as a consultant in respiratory intensive care in a hospital that only deals with tertiary referrals in heart and lung disease. A role further removed from the care of the DGH acute medical take it is difficult to imagine. In my view the general physician is an illusion and I say this as someone who has carried the label earlier in my career. The truth is that the majority of consultants are uneasy when practicing outside their comfort zones (i.e., their speciality), those that aren't are deluded. I shudder to think what would happen if I had an acute GI bleed and was cared for by a cardiologist 'dabbling' in general medicine (as I did). All the evidence indicates that my outcome would be better and my stay in hospital shorter if a specialist were involved from the outset. In my view this is what the college should aim for. This will inevitably mean closure of smaller acute hospitals to centralise specialist care (for which I appreciate there is no political will). Pointing the finger across the Atlantic to highlight the expansion of hospitalists in the USA is inappropriate. We already have hospitalists in The UK, they just don't work in hospital, they work in primary care and call themselves general practitioners. If we are seriously intending to copy an American model of health care, we really are in trouble. Finally, am I the only one to spot the irony of the College promoting expansion of the generalist at the same time as it publishes a document 'Hospitals on the edge', highlighting the crisis in recruitment in acute medicine and geriatrics at consultant and trainee level. Who will fill these vacancies? Either an underclass of physicians or our high quality trainees forced into jobs they don't really want?
Anonymous
Mind the Gap !
I am deeply concerned that the Royal College of Physicians is conducting such an exercise at a time when both the Liberal and Conservative Parties are clearly looking to - slowly privatise - the National Health Service . No doubt there will be those in senior positions in the - National Health Service / Royal College of Physicians - who will do well financially from such a transition and couldn't give a fig about the NHS and the values that set it up . Robin Rowlands - (@Mothbitten) Guildford UK