The psychology of insults…
‘…all insults are projected from a place of fear and ‘lack’. The insulter will insist they are simply pointing out your flaws, but actually…. they’re pointing out the difference from what they know or what they understand, or the lack of it.’
Seems about right to me.
Particularly in the light of the extraordinary attack the President of the Royal College of Emergency Medicine, Adrian Boyle, has unleashed on inpatient-teams… colleagues.
Boyle is boiling because…
A Trust in North Bristol is accelerating patients through their system and out of A&E, onto the wards, using ‘risk-sharing’.
In English; A&E patients are shifted to the ward they are most likely to be admitted to, whether or not there’s room on the ward. Irrespective of bed capacity.
Patients are ‘boarded’ or doubled-up in the expectation ward-staff will somehow discharge other patients quicker.
Boyle is out of his pram because not all Trusts have an appetite for the risk involved and not willing to take on the idea. He complains;
‘… too often there is an acceptance of unacceptable delays [and risk] in ambulance handovers and long ED stays.
‘Where this fails, it is usually because inpatient teams (both nursing and medical) have objected to the extra workload, without appreciating the real harm elsewhere…’
I think the phrase ‘objected to the extra workload’ is one of the most crass statements I’ve heard for a long-while. .. adding to the ‘toxic’ culture the NHS Ombudsman reported last week.
If people working in the NHS ‘objected to the extra workload’… it’s very likely there’d be no one working in the NHS at all.
Is Boyle bonkers?
He compounded his insult by implying it was a lack of leadership; ‘failing to encourage people to think system wide’.
Winter’s on the way. Things’ll get worse. Politicians and tabloids will seize on Boyle’s gratuitous insult… ‘See, they’re all lazy, a top doctor said so’… I can imagine the headlines.
Only team-working will see the NHS through. Implying people are work-shy, won’t.
Boyle likes Bristol’s ‘continuous-flow’ model. It’s been in use in the US and Australia.
However…
… both Australian and US studies found that hospitals which ‘speed up’ processes and decreased length of stay in response to emergency department overcrowding, increased their 30-day mortality by 3.8%, which means 2.3 additional deaths per 1,000 patients per year.
Last month, writing on ‘boarding’ in a blog for the Nuff’s, Dr Louella Vaughan said;
‘… ‘boarding’ patients has been shown to nearly double the mortality on the wards and within 30 days of discharge not only of patients directly experiencing boarding (from 2% to 4.2%), but … for all patients on wards where patients are boarded (from 2% to 3.7%).
The practice was found to increase length-of-stay for all patients on wards with ‘boarders’ and to increase readmissions for boarders themselves.’
A&E is under huge pressure. The appeal of continuous flow protocols is that it makes the problems ‘visible’ across the hospital. Spreads the pain.
However, as Vaughn observes;
‘… overcrowding on the wards has the potential to impact substantially more patients, if not all patients …
… even a very small risk translates to a very large number who might be potentially harmed.’
Less than 20% of problems with delayed discharge are down to hospital staff.
Most discharge delays (66%) are caused by waiting for community-sector-services.
Pushing-to-discharge risks patients being sent home early, [or] in the wrong place, simply for the sake of expediency… and very likely to end up back into the tender care of Dr Boyle and Co.
Transferring Boyle’s problems to another part of the hospital is to defy queue-theory.
Simply;
… if a system can handle 100 events an hour, then 99 events are a breeze. 101 events and the system collapses. In the next hour the collapse is a catastrophe. In the next… calamity.
It’s called latency.
Parking ‘events’, or in our case patients diverted to a ward, is called ‘a queue-in-between’.
All it does is create another backlog.
Another queue where yer-granny is warehoused and why the front-door of A&E looks like a secondhand ambulance auction.
The system is overloaded.
Queue theory tells us to fix ‘overload’ by limiting access… in NHS speak ‘admission-avoidance’ but… everyone is too busy and there’s no money for serious system-redesign.
We can’t refuse people a place in the queue, so the service degrades.
We can’t fix overload, so it chokes-up.
We can fix the root-cause…
… social-care’s capacity, HMG’s unwillingness to pay for a solution and help them to keep up.
Boyle should be aiming his insults at No10 and their ‘unwillingness to take on the extra workload’ and fix the problem…
… not bad mouthing colleagues.
News and Comment from Roy Lilley
Contact Roy – please use this e-address roy.lilley@nhsmanagers.net
Reproduced at thetrainingnet.com by kind permission of Roy Lilley.
