We need to talk about urgent care..

I told my family about my blog…. They said I should write about our recent experience of urgent care , with my Mum. I mentioned it briefly in my last blog… The urgent care experience we had really underlines all the issues that face us collectively as a system…




It was Bank Holiday Monday ( it always seems to be..) my Mother, who is 93 and frail, felt dizzy. She didn’t feel well enough to stay alone at home. She was afraid she would fall, she has done several times before. She has carers who come in three times a day. They work for an agency. They don’t get paid for travel between clients. They tell me their only training is a DVD given to them when they start. They are always in a rush. Sometimes in a week she can have 15 different carers, and the turnover is huge. My Mum has dementia and new people make her anxious. So staying at home with the care she has wasn’t an option. Mum has been failing for the past few weeks and we had had several conversations with Social care that she needed a different place to live. Extra care probably, somewhere with resident care, but it hadn’t moved fast enough and following 2 previous hospital admissions in 3 weeks we were once again in a mess. My brother called GP OOH, or at least NHS111. What followed was a wearisome 50 minutes of repetitive questioning.. and holding…. Different people reading computerised questions.. did she have chest pain? weakness? Finally we spoke to someone who offered us a GP visit… I was an out of hours GP until very recently. I could triage a phone call safely in 8 minutes max.. although I usually had a good idea what was going on within the first minute. Is it surprising more of us are simply giving up and going to A&E

So the GP came… he wasn’t local and didn’t know much about local services. He didn’t think she was “acute” but clearly wasn’t well enough to stay at home. The Acute Trust refused to see her. The GP had no idea about intermediate care ( although the Acute Trust- who also manage community care say there is 24/7 access on their website) The only phone number the GP had for district nursing went to ansaphone. So now what? After 2 hours the GP phoned 999 for an ambulance and my Mum went to A&E. WE were advised NOT to go with her because if we did they might just send her home…

We were left feeling we probably should have phoned 999 straight away but we knew she didn’t need that really.

The next day I went to the acute medical ward at 9am. I knew the doctors would be there then I was informed, a little brusquely that is wasn’t visiting time and everyone was busy. I pointed out that my Mum has dementia and therefore is both confused and frightened so I would like to sit with her for the ward round…using some medical terminology and the Dr title helped I think as I was allowed to stay. We agreed my Mum wasn’t acutely ill but needed to be in a more supportive home environment. A social services assessment was arranged. I went to work… an hour away. I was then phoned to say the assessment would take place in 45 minutes on the ward. As luck would have it my daughter has a week off uni, lives in the same town and was free to go to be with her. My daughter then witnessed a row between the staff nurse and the social worker about how long it would take to organise a placement for my Mum, which only stopped when my daughter interrupted and asked them not to talk about her grandma like a piece of smelly baggage no one really wanted. The outcome: a short term nursing home placement and a long term change or residence hopefully to an extra care flat, if being in the nursing home didn’t lead to too much loss of independence and confidence whilst we waited. Her discharge was delayed ,even then, because the Doctor in change of her care decided at the last minute an echo might help… after 3 more days, an increasingly confusion and no echo and with the help of a very enlightened Sister, I all but kidnapped my Mum and took her to the nursing home…

We talk about the problems in urgent care. Lots of people have tried to look for who to blame. The problems like most in the health service as complex, wicked…. If they were simple we would have got it right be now. The evidence tells us older, increasingly frail people attend A&E with complex problems. In our own area we didn’t see much of an increase in numbers of admissions in November, December and January, and yet the hospital was really busy. The people in hospital were older and more frail and took longer to be sent home. So urgent care is linked inextricably to care for older people. Stopping them going into hospital in the first place and getting them home as soon as possible….Get that right and the A&E issues will diminish…ignore it and focus only on more A&E services and nothing will change… treating the increase in minor problems and the worried well is relatively simple…

And how long will it take us to realise the ONLY way to make NHS111 work for patients and the system is to have highly qualified people at the front end.. doing triage straight away. More expensive in terms of labour costs- YES but system wide it will save by reducing unnecessary blue light trips to overcrowded A&Es and most importantly will make the service better for patients.

And can all of us remember every day and every time that patients are just people in nighties and pyjamas, but they still need to be treated with respect and kindness.

Flowers for my Mother

Everyone is talking about leadership…. There are courses, books (one of the best have found is one called Intelligent Kindness by Ballatt and Campling which I really like) and conferences everywhere I turn. It is apparently the answer to IT all. Although I am not quite sure what the IT is. When is leadership something different from management? Is there really a difference between clinical and managerial leadership? It seems that clinical leadership is now the in thing…and I am glad about that because it has given me the chance to take on this role rather than be left to sit on the side-lines as I have done in various PCT roles in the past and people actually listen to what I have to say now which is novel! but what do we really mean by leadership anyway…



My mother was admitted to hospital three times in the last three weeks. She is 93 years old and has dementia. Up to this point she has lived quite successfully in a small flat with a day time warden and a life line service but clearly things are getting more difficult. As a family we experienced the wonders that are the fragmented, patchy, variable services for older people. I am sure our experiences will not be that different from everyone else’s across the country. Where my mother lives is an average sort of place with an average sort of trust and an average GP. Nothing extraordinary but okay. As we navigated through out of hours services, acute medical wards, wards for older people, community hospitals, social service teams , care homes, what became obvious to me is the huge variability of attitude, approach and energy within one small location. The worst experience by far was trying to get help initially and the tortuous map of repeat questioning( does the system have dementia?) and changing personnel that is NHS111….. 50 minutes to get to speak to someone who could maybe do something… To the best… a small community hospital with the attitude that it will make the right thing happen and that each person is important and valuable..



What made the difference? Dare I use the word? Leadership…. visible leadership… in the community hospital the matron is brilliant, she leads by example. She cares, she bothers, nothing is too much trouble… and everyone in that hospital is infected with a sense of purpose and achievement. It feels good to be there. The staff smile, they stop and greet you when you walk in. They don’t rush by with their eyes to the floor.. looking busy and hassled….My Mum was happy there, I was relieved and happy she was there. She made progress. But why the variation? It cant be right can it that each little building block of the NHS is so dependent on the individual in charge. It makes it far too fragile… So within a huge organisation made up of so many tiny parts how do we drive up quality everywhere? It feels like an impossible task. How do we get 100% excellent CCGS doing great commissioning and all trusts and All GPS caring for patients to the highest of standards? Because that is what we want for our mothers, our children, ourselves.. what is acceptable variation? We know that 50% of anything is below average, just by the definition of the word , but we have to reduce the distance from worst to best so that the variation isn’t big enough to feel from a patient perspective. The only answer I can come up with is something about the leadership of the whole system, not of each hospital or CCG but of the whole NHS. It needs to be different, palpable, with core values that are lived by everyone in the work they do every day.. Where leading can be kind. Not soft or sloppy, but intelligent, and caring. So each part of the NHS, each layer each organisation can look up and se those values everywhere. No bullying, no intimidation, no weasel words to avoid answers. AS NHS staff, managers, clinicians, support - senior or junior we have to treat each other with the same values we expect and value as patients. WE must never forget that we are all potential patients in the system we design…. my guiding principle as a GP has always been ..would this be good enough for me.. my family… if not then it isn’t acceptable for anyone….



The new NHS is an experiment… it allows a whole garden of flowers to bloom…it is a risky plan especially in such a cold and cloudy time…as a new flower ourselves I applaud that but it relies on a gardener who understands how to get the best from each variety, and how the species interact with each other. She needs to be present, visible, dealing decisively with the weeds and with those bits that overgrow, or aren’t healthy… watering, feeding, nurturing, and providing the environment that will support healthy development whilst being clear about the overall direction and shape… gardening a system requires patience , vision, permissive bravery and the wisdom to act decisively but kindly when necessary.



My mother was bewildered by the labyrinth of services she encountered….. do we have the collective will and the imagination between us and together to work with the system we have and make it work for her?