On bed crises and their fallout

The hospital at which I am currently working has been struggling over Christmas with the number of people coming in to A&E. Just as those tiresome leaves surprised train bosses every autumn by falling from the trees, so it always seems to surprise hospital management that more people get ill and come through the door of A&E in winter.

Unsurprisingly, the local people already know that waiting times can be bad. They know it not because of the huge waste of money that is NHS Choices, but because they actually live near it and come into it occasionally, and they mentioned long waiting times as a big problem in the survey; the hospital's response is not to look at why wait times are long, not to look at where the process could be improved - instead they just carp on about how much money they're spending on A&E (1.5m quid, if you're interested), and add the fateful "And we never close our doors to admissions."

It seems to me that this is indicative of many of the problems with the way the government and the department of health have gone about changing the NHS. There is almost never a reasoned analysis of why problems exist; those working on the frontline - doctors and nurses - are never consulted, and instead overpaid idiots dream up a way of wasting as much money as possible so they have a bigger headline figure to take to the press. That last point is what has driven government policy on the health service over the last decade - always "we are spending 10m quid on it, so it must be good", and the idea of actually engaging with and supporting the people doing the work never enters their stupid, pompous heads.

It trickles down, too - in my hospital the vogue for frittering money away on consultants resulted in management rounding up some local businessman who is doubtless very successful in the small estuary town in which he works. He came in and told us all about Toyota lean manufacturing; the upshot of this was that patients' notes were moved on some wards from a single trolley at the nurses' station to four or five small trolleys by the bays, the rationale being that they would be closer to the beds and so you would save time.

Before you read on, ask someone who works in a hospital what the commonest cause of spending time looking for notes is, or ask yourself if you work in one yourself. I'd hazard a guess whoever you spoke to said "some bastard leaving them littered around the place". The solution, therefore, is simple - either make the things electronic (difficult if you do it centrally via something like the disastrous National Programme for IT, easier but still costly to do locally) or encourage people to put the things back properly. Not easy - you need to get all the groups who take them out of their appointed slot and leave them places to stop doing so, and everyone does it - but everyone wants it to happen, so doable.

What we have instead is a system where in the past you had to look on one notes trolley plus the desk surfaces which were immediately adjacent to the notes trolley, you now have to look through five different notes trolleys dotted all around the ward, and you still have to check the desk surfaces as well. Genius. As you can imagine, management can't get enough of trumpeting this rather doubtful "best practice".

Similarly, their management of the bed crisis is stupid, although in their defence here it is governed by the unshakeable, immutable stupidity of government policy. In short, the reason that "we never close our doors" is currently that "we" are closing everything else down to create more bed space. The most recent was the closure, without any notice or consultation of staff or parents, of the on-site centre where children with complex disability get rehab. The chief exec turned up on friday and shut it; the builders moved in on monday morning.

Perhaps they thought children in wheelchairs would be less able to fight back? After all, we can't fall foul of DoH rules by saying "sorry, we're full; try somewhere else", because that would cost the trust money. Instead, we'll stop seeing 150 kids a day who desperately need this support in favour of putting 22 people with flu in the same space - and that's not even 22 people a day. The backlash, such as it is, has started, but it's hard to make these people listen.

The really ugly thing about it is that, as the staff working here, we know when we can't take on any more patients, and I'd suggest that when we've run out of beds we are probably at that point. Certainly no one would want to cut vital, careful, developmentally-crucial services to kids in favour of short-term management of illness and what must be a huge locum bill for staff who at best don't know the hospital and at worst are undertrained for the jobs they're being asked to do.

But we don't have a say in it. We just get told when to leave the building.

And in case anyone is reading who has been affected: sorry.

The CFSMS: they may be useless, but now they can read your patient records!

The Department of Health have recently issued a code of practice allowing the characteristically catchily-named "NHS Counter Fraud and Security Management Service" to demand 'documents' from doctors. Rumour has it there was a consultation prior to this being made law, but information on who was consulted is thin on the ground.

It appears that what this means is that the CFSMS can oblige any doctor in the country to hand over confidential patient records or risk prosecution, a fine, imprisonment, and a criminal record. Which is obviously a little worrying, as anything which forces us to hand over private information about patients without their express permission risks making them think we're all untrustworthy bastards whose aim in life is not to help them but rather to lull them into a false sense of security before shopping them to the police. And heaven knows we medics don't want to become like MPs.

The CFSMS describe themselves as "a division of the NHS Business Services Authority [with] responsibility for all policy and operational matters relating to the prevention, detection and investigation of fraud and corruption and the management of security in the National Health Service." What this appears to mean in English is that they are responsible for several different things, including:

(1) The NHS Security Management Service (SMS), which tries to stop people assaulting NHS staff. This of course is a perennial problem in hospitals, particularly when the drunks stagger in to A&E after their friday-night beatings looking for softer targets. The SMS took this on in 2003 under the expert guidance of Patsy Hewitt, and their success was evident by 2005, when a national audit showed 2 in 5 clinical staff and 4 in 5 nursing staff had experienced violent or threatening behaviour while at work. The audit in 2006 followed DoH form by seemingly reporting two different things at once - the headline claimed that "the number of NHS staff being physically assaulted has fallen", but the same report stated "despite the overall fall, assaults against staff working in NHS hospitals rose last year". On reflection, this may be thanks to fewer assaults on NHS staff working in community mental health; a cynic might argue that the reduction there could be explained by the ever-smaller number of NHS staff actually working in community mental health. If anyone knows where to find those numbers, it'd make for an interesting analysis...

In 2006/2007 the numbers fell slightly again, but there were still 55,709 physical assaults on NHS staff and the CFSMS managed to prosecute, er, 869 of them. Being a well-trained bunch of unelected DoH / government incompetents, they chose to report this as "a 17 fold increase since 2002-2003". Which is absolutely shameless given that in real terms, after four years of taxpayer funding (including an additional payment of £97 million from Alan Johnson in September 2007), they were managing to prosecute less than 2 assaults per hundred.

The SMS also draw up more of the policy documents which the DoH appear to prefer to, for example, health spending - their summer 2008 newsletter (which has lots of photos of Gillingham FC players, if you're into that sort of thing) announced "a policy template for the management of security in healthcare organisations". While their willingness to use plain english in the document title rather than attempting to stuff as many syllables as possible into it is commendable, it does seem to have taken the NHS Security Management Service four years to draw up a policy document covering, er, the management of security in the NHS. Does anyone know what they were doing for the rest of the time?

(2) And what of the NHS Counter Fraud Service (CFS), you may well ask? Given that they apparently "investigate all cases where there is evidence of corruption involving a public official who is using their public influence for private gain", I was hoping they might have prosecuted that evil old harridan Patsy now she's started using her experience of public healthcare to assist such champions of the private sector as Alliance Boots, the private equity company Cinven (who recently bought BUPA's UK hospitals), and the BT group. Alas not.

Their most recent newsletter announces that they've shopped some fraudulent dentists, which is good although perhaps suggests that all the honest ones left when presented with the new NHS contract. They also got an orthopaedic surgeon who was claiming sick pay from one hospital while working at two others struck off and imprisoned - which while obviously a Good Thing, does beg the question of how exactly the systems in place allowed the same doctor with the same name and the same specialty to claim money from three different places at once. Similarly, 65 dentists claimed more than 2 million over three years for gold teeth, with one bloke claiming 11.4 million over that time. Did no alarm bells go off beforehand about that? Or were they too busy looking for the bolt on the stable door to notice? Perhaps this is overly harsh, as it is obviously good that these people are being brough to task - but how do the systems in place allow this to happen?

They also look at the problem of health tourism, but don't give much information on how they've managed with it.

And this is where the real problem lies. Let's say I as a doctor see someone in A&E in need of urgent treatment. If they're in extremis, I don't have time to ask to see their passport, visa, proof of address, any of that - I'm going to get them fixed up after their car-crash, or stabbing, or get them treated for their chest infection. In most cases, I have no problem with their subsequently being pursued for the cost to the hospital of, say, putting a cast on a broken leg (although I worry that, particularly given the CFSMS' apparent track record, we as taxpayers will end up shelling out far more chasing these guys than they can ever afford to pay.)

There is a twist. Tuberculosis is a rising problem in the UK (as indeed are a large number of other infectious diseases), particularly multi-drug resistant TB. If I get someone coming in to A&E with suspected TB, it is in the national interest to treat them - the healthcare costs alone of treating all the folk they go out and infect are dramatically higher than getting the one person early, and that's before you factor in the economic costs of days lost to work and so on. If word gets around, though, that coming in to A&E with a cough means you get arrested, fined, and deported, your average illegal immigrant won't ever dare to set foot in an A&E department, because they won't trust us as doctors to treat them in confidence.

In that scenario, the trivial costs you recover from some poor bastard who comes in coughing his lungs up before you ship him back home are dwarfed by the increased burden you put on the NHS when his roommate infects a dozen people over the next year because he knows better than to come into a hospital.

There are a number of provisos and specific conditions which the CFSMS need to meet to be able to demand documents - they're outlined in the document itself - but I have grave doubts as to how this will be used in practice. I suspect it'll be used so the CFSMS can give the government a few Illegal Immigrants Sent Home in the press and so justify their own funding, and the upshot will be the left hand taking back 10p while the right hand has to pay out a quid, and a population that trusts doctors that little bit less. We'll see.