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In a thoughtful composition, clear lightbulbs hang suspended from a rope, reminiscent of innovative ideas illuminating the path forward in hospitals and the NHS. A beautifully blurred background subtly accentuates this inspiring scene.

Think

As it disappeared into the distance, the dirt road was cast in the orange, dappled light of the warm, evening sun.

The Jacaranda trees swayed in the breeze. Bougainvillea petals floated across the assure pool…

… no, I’ve not got a touch of Monday morning madness…

… it’s just that last week the HSJ published a leak of a ‘confidential working draft’ of NHSE’s Urgent and Emergency Care reform plan…

… and it is so desperately bad that I was looking for a way to bring it gently onto your life. Plop it onto your desk. Rather than the on-high, thud that is the way of most junk-mail.

I should emphasise, it is a leak. An early working draft but it does tell you something about the direction of travel and the paucity of thinking. 

It starts with a white flag.  

Streeting’s original promise was to get the four hour A&E target back to 95%. They’ve given up on that.

This plan leaves it where it is now. Another year at 78%.

If the final decision is to seek no improvement, what’s the point of a ten-point plan?

Dunno.

If they are not substantially reducing the dwell-time in A&E (the only thing the public care about, when they are marooned on a plastic chair for hours) what’s the point?

Trusts have a choice; crank the less serious conditions through the system… let the complex one’s wait… improve the target performance.  

Or, sort out the serious ones whilst the others wait… and never reach 78%

One of the ten points is to reduce the number of NHS111 calls put through to 999, by introducing more ‘clinical validation’.

Up-shot; expect to wait longer for somebody to decide where to send you. 

The draft talks about a 2% improvement by prioritising capital-funding for more urgent treatment centres…

Up shot; expect to wait ten years.

There’s lots more.  

Improving vaccination rates. 

How? Dunno. 

How about;

  • Obligatory for children to attend school? 
  • Obligatory for all NHS people, shop workers, anyone using public transport? 
  • Obligatory for employers to offer vaccinations? 
  • Obligatory for everyone of working age?  

Obligatory? Ouch… but… persuasion has not worked. Good luck with that.

Rapid triage is next. In essence putting a consultant at the front door. We know that works and if there are any A&Es not doing it, they deserve all the queues they get.

There are three corkers; 

  • getting into a hospital bed more quickly for ‘those who need one‘, 
  • shorter length of stay, 
  • reduce discharge delays…

… which are the three persistent problems A&E endures when they have no space. Restating them in the wish that doing so will provide answers is management by fairy-dust.

Read the thing for yourself. It’s worth the price of an HSJ subscription, even if they print nothing else for the rest of the year!

There is a ray of light; relaunch ‘discharge ready dates’, data. Of itself not very interesting but on a national basis, will reveal variation… but, useless without the money and people to do something with it.

For the umpteenth time, let me say again…

… hospitals wards and A&Es are full, mainly, with people over 65 and kids under 9yrs.

Last year 200,000 older people came into NHS A&Es from care homes.

How loud do you have to shout;

THOSE ARE THE 3 THINGS TO FIX.

Invest in; primary care, community teams, fold adult social care into the NHS.  

Instead of retiring; make it easy for older, experienced nurses to work in the community (they don’t because whatever their hospital Band, they have to go back to Band 5 in the community). 

Oblige care homes to employ experienced nurses, who can prescribe.

The authors of this draft are guilty of several management sins;

  • Surface-level-thinking. See it fix it.  
  • Attribution bias… looking only at visible factors.  
  • Root-cause avoidance… and, 
  • Because they are a hierarchical department… confirmation bias.

The worst cocktail of management thinking, possible.

Identify the right problem and you’ll see; no reform required.  

Try the simple 5-Why test.

Hospitals are full of older people and kids

1.Why?

Because they don’t have sufficient support where they live

2.Why?

Because we don’t sensibly resource community and primary support

3.Why?

Because we allow our thinking to be drawn to resolving outcomes that are visible and dramatic in hospitals. Not the root causes

4.Why?

Because we use symptom based thinking… solving what’s on the surface

5.Why?

Because the NHS is constantly reacting to problems and has a firefighting mentality.

Yes, that’s why! So to change A&E, change how you think.

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.

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