Doing locums in NHS A&E departments is a great way to get an overview of the health service in Britain. Whoever thinks that there is a certain nationwide consistency because, theoretically, all hospitals are part of the same organisation - the NHS - will very soon learn that this is not the case.
Procedures followed; treatment protocols adhered to; equipment used; administration; standards of cleanliness; personnel policies; or any other parameter imaginable vary wildly. This is not necessarily a bad thing because it offers the option to compare practice and outcome and gather experience that helps to develop a solid, evidence based “best practice”. Well, at least in theory …
However, sometimes one comes across a hospital that is like a metaphor for the entire health service. As you enter this hospital, you cross a zone like a minefield, strewn with chewing gum and cigarette butts on the floor. Nicotine addicts huddle around the entrance doors inhaling their drug under the patronising posters that tell them not to.
The posters and signs claiming that the entire estate is supposedly smoke-free are ignored for the simple reason that the Trust does nothing to enforce it. Thanks to the anti-smoking policy, there are no ashtrays and thanks to the policy not being enforced, the entire place looks like a big, walk-through ashtray. How to achieve the worst of all options? NHS administrators effortlessly show the way.
On to the A&E department. At this hospital, that is in the basement. No daylight and no fresh air. No adequate ventilation system either, but some ventilators randomly distributed all over the place which keep the same stale air moving in some parts.
The smell is nauseating and the air quality is of the kind that every sensitive person will have a splitting headache within half an hour. Patients on trolleys are assembled like a herd of cattle on the main floor, twenty or more at a time, because there are nowhere nearly enough cubicles. Patient dignity and privacy are non-existent.
Doctors have to chase a free space to see their patient, and then navigate the trolley with the patient through the crowd in order to reach a cubicle. Is this the best way to use expensive doctor time? The Trust seems to think so.
The real struggle when trying to see a patient begins now: the fight against a computer system that has the information about the patient distributed over several Intranet websites, the ordering for investigations made elaborately complicated and time consuming and the returning results to be collected one by one from several web pages. There is no such thing as one unified electronic patient record that shows what has been done, what is planned to be done and what investigation results are available on one patient.
Yet this would be a crucially important feature of patient safety: to have all information in one place ensures no important piece of information is missed. The computer system at this hospital is far from being a help for the doctors. It is the exact opposite: it is an obstacle.
The result is that out of ten doctors on duty, eight are sitting in front of a computer screen at any given moment. Patient contact is minimal and fleeting – the needs of the computer system come first. Any doctor new to the department who is serious about patient safety will be slowed down enormously as it is basically impossible to keep an overview over several patients while trying to come to grips with the cumbersome digital administration system.
There is no such thing as a perfect admin system, some are better, some are worse, and then there is this hospital …
However, what really made my brief experience in that hospital unforgettable was something much more basic than the digital admin system. I have worked all over the world, but I have never, absolutely never seen such a dirty hospital – and that does include places such as Nigeria. Obviously for reasons of patient confidentiality I did not take any pictures in an area where patients were. The pictures you see have been taken in the corridor and staircase that connects the department “shop floor” with the A&E offices and staff room.
This means: the head of the service, her deputy and every senior doctor with an office walks through there and has the view you see right in front of their eyes every time they go to their office. Actually every single member of staff sees it during their break on every shift when they access the staff room. It also means: this dirt will be distributed to every corner of that department via the soles of staff shoes on every single shift.
The truly amazing thing is that nobody, absolutely no-one in that department seems to notice this filth right in front of their eyes. When I mentioned it to one staff member, the answer provided the key to understanding today's NHS.
Me – pointing at the massive fluff balls: “Why is this place so dirty?”
Staff member: “I have no idea. I mean, it does get cleaned regularly, which is documented”.
Now hold on for a moment and look at the pictures again. In the pictures you see the exact spot the staff member and I were looking at when we had this conversation. To anyone living in the real world, it is absolutely clear that the place has not been cleaned for a very long time. Yet that NHS staff member believed it has been cleaned – because the paperwork says so!
This little conversation is the key to understanding the NHS: the real world, the reality right in front of the eyes, the touchable, smellable, visible reality ceases to exist when the paperwork says differently.
In the NHS, the victory of bureaucracy over reality has been total. Reality is what the paperwork says, irrespective of what you can see in front of yourself.
Once you take up the chain of thought this implies, you realise why whistle blowers are that hated by NHS managers: for them, the whistle blower created the problem, because he/she made it enter the paperwork.
Only by entering the paperwork, the problem became a problem for the NHS bureaucracy, because for as long as it is not documented, it does not exist for them. This is why the problem is not the problem in the NHS, but the one who documents the problem is the problem!
It is therefore absolutely logical that NHS management tries to solve their problem by eliminating it – which means eliminating the whistle blower. The issue will then solve itself because by eliminating the whistle blower on that issue, nobody else will dare to do anything about it. That will keep it out of the paperwork and if it is not in the paperwork, it does not exist. Sounds crazy? Just think about it step by step: it has its own inherent logic!
This brings us to the sometimes astonishing results published by the hospital inspectors. These inspections are announced and usually timed to cover the least busy times (co-incidentally, of course). Extra staff are drafted in and even the cleaners have been through with a mop to make the place look presentable during the few minutes hospital inspectors spend on the shop floor. After that they go down to business: quango bureaucrats inspecting the paperwork produced by hospital bureaucrats.
The more money thrown at the NHS in its current form, the more of the same will take place. If the Department for Health was serious about inspecting hospitals, there would be a cohort of “mystery” patients, mystery locum doctors and mystery locum nurses touring the country with no hospital having any idea if and when it has been inspected.
As it is, “hospital inspection” is a job creation merry-go-round for bureaucrats. More quangos demanding more paperwork, thus justifying hospitals to hire more bureaucrats, and so on and so forth for some thirty years now.
If the British people want a better health service, they have to dismantle the bureaucratic monster the NHS has become and hand power & responsibility back to where it should be: the senior doctors.
Addendum: This is a picture of the hospital my article is about. It symbolises all that is wrong with the NHS: centre spot is given to a political agenda, political correctness. That is what the brand new, big and centrally positioned rainbow flag stands for. Health care is a fringe concern. That is what the knackered leftover bits of the NHS flag on the side stands for. Everything in one picture...