Theatres can be surprising. As I discovered on a hospital project

Avoiding the avoidable is an excellent goal. But sometimes healthcare, including acute healthcare, is simply unavoidable. Not all the people walking into Emergency Departments are ‘walking wounded’ or ‘worried well’ who can be sent home with instructions to see their General Practitioner in the morning. Some really need hospital care and have to be admitted.

However, avoiding the avoidable doesn’t stop at the hospital bedside. Work still needs to be done to make sure that even within a hospital stay, the care delivered is precisely what the patient needs, and no more. In that context, initiatives that I’ve mentioned before that focus on discharge planning are important: from the moment of admission if not before, work needs to be put in place to discharge the patient as quickly as possible:

• The patient should not have to stay longer in hospital than they need to just because test results are not available
• If necessary, doctors have to review the organisation of their work to ensure that all the necessary paperwork, including prescriptions, are signed and ready in time for a prompt discharge
• Where hospitals have to ensure that a patient is discharged to an environment with adequate care, all the arrangements should be in place beforehand

That’s the surest way of avoiding unnecessary hospital care: get the patient out of hospital and no longer incurring the elevated costs of nursing, medical care, tests or hospital drugs, to say nothing of surgery.

Even while in hospital, we can take action to avoid resource wastage. That’s where good information services come into their own again. Sometimes, they don’t even need to do anything exceptionally clever: they simply have to report in a clear and undeniable way on what’s going on in the hospital.

Often, that kind of reporting does just one of two things, both useful:

• It may confirm what everyone knew, or at least suspected, but couldn’t prove
• It may surprise people who hadn’t anticipated that the problem would exist

Occasionally, the same piece of information may confirm one person’s suspicion and surprise another. That happened to me when I was working, many years ago, on a reporting system for theatres (as we quaintly refer to operating rooms in the UK) in a major acute hospital. Theatres are hugely costly, both in the amount of capital they require – not just for building space but also for equipment – and in their running costs, requiring large numbers of highly-qualified staff in relation to the numbers of patients. It’s no surprise that many cost-containment initiatives in hospitals make a specific point of working on cutting unnecessary theatre costs.

One of the costliest areas in a hospital
so no bad place to look for economies

The project was fun because we set up a live link between our reporting system and the theatre management system. That meant we could see what stage of an operation any one case had reached: arrival in theatre, start of anaesthesia, first cut, last stitch, out to recovery, return to ward.

I appreciate that’s only fun for a geek who’s got too used to working on retrospective reporting systems, as I was: to me, it was exciting to be able to follow individual cases in near real time, as the theatre nurses entered information on their own system.

The real surprise came, though, with one particular report. We hadn’t been second-guessing the users at all, but building reports only as they told us they wanted them, using information they’d asked to collect. One of the reports, however, struck me as singularly dull. It simply showed the number of cases when the patient had been due to have a general, regional or local anaesthetic, plotted against which type of anaesthetic was in fact administered. The report looked something like the fictitious example illustrated (from memory – please forgive any implausibility it contains).

Anaesthetic report: I couldn’t see what was so exciting about it

The Medical Director of the hospital was also the head of anaesthetics. He looked at the report and immediately crowed with delight.

“That’s what I thought!” he proclaimed triumphantly.

I looked again at the report. I couldn’t see anything inspiring in it.

“Look at all those times they asked for a regional or general anaesthetic and ended up using a local! What a waste of an anaesthetist’s time, standing by to administer the anaesthetic, without being required.”

Suddenly the report made sense, as did his reaction. And I made a mental note: don’t imagine you know everything a reporting system should do. Talk to the users, learn what they want, and you may come up with something that will surprise you and delight them. 

Particularly if it highlights an area of waste that can be avoided.

Ageing: a crisis for healthcare. Or an opportunity for integrated care?

It’s obvious, isn’t it? The wealthy nations face a crisis due to their ageing populations. The problem’s particularly acute for healthcare.

It’s so obvious that even I have said it in the past. But it isn’t entirely true. The error needs correcting, if only because ageing isn’t a curse but a measure of unprecedented success. At the beginning of the last century, life expectancy in the US was just over 48 years. Today, it is nearly 79. In Britain over the same period, it has grown from 45 to 81. How’s that a disaster?

After all, it’s not as though the picture is the same everywhere. In Syria, life expectancy is 64.5 years. In Sierra Leone it's just 50 years, little better than the US over a century ago.

Where there have been gains, the extra years include an increasing proportion in good health. That’s according to a study by the British healthcare think tank, the King’s Fund. It suggests the trend is likely to continue, with our ageing population adding further years of healthy life.

More years of healthy life? Why’s that a problem?

Not so much a healthcare crisis as a cause for celebration, surely. 

That being said, the trend does raise new challenges for healthcare. They need to be addressed. That means a change in approach.

As the King’s Fund points out, what we are seeing is an increase in the specific kind of health problem characteristic of old age. There are more long-term conditions such as diabetes, some lasting for life, and more patients suffering from several disease conditions at the same time.

Why is that such a challenge to the health services? Because historically healthcare has been built around specialisation. Hospitals are organised into departments dealing with neurology or rheumatology or cardiology. But today they’re having to deal with patients who may have suffered a stroke exacerbated by a chronic heart problem, who are also struggling with the pain of rheumatoid arthritis.

How does a specialist of just one of these conditions approach such a patient?

These issues also raise the question I’ve been addressing throughout this series: in what setting should a patient be treated?

The King’s Fund tells us:

…we must strive wherever possible to ‘shift the curve’ from high-cost, reactive and bed-based care to care that is preventive, proactive and based closer to people’s homes, focusing as much on wellness as on responding to illness. When asked what they value in terms of wellbeing and quality of life, older people report that health and care services when they become ill or dependent are only part of the story. Many other things matter: the ability to remain at home in clean, warm, affordable accommodation; to remain socially engaged; to continue with activities that give their life meaning; to contribute to their family or community; to feel safe and to maintain independence, choice, control, personal appearance and dignity; to be free from discrimination; and to feel they are not a ‘burden’ to their own families and that they can continue their own role as caregivers.

Admission to hospital may be vital in certain circumstances but, as well as being the most expensive way to deliver care, it corresponds to only a tiny part of the aspirations older people expressed to the King’s Fund team. They propose reform based on nine points:

1. helping people maintain their independence, to live at home in good health, for as long as possible;
2. helping people to live as well as possible with simple or stable long-term conditions if they develop them
3. helping people deal with complex or multiple health problems, including dementia and frailty
4. in cases of real crisis, delivering rapid help close to home
5. when it becomes necessary to provide hospital care, making sure it’s good and delivered humanely
6. planning discharge from hospital on admission or before, ensuring patients leave with sufficient support and avoid the risk of readmission
7. providing good rehabilitation and re-ablement services so patients quickly return to the best possible level of health and independence
8. providing high-quality long-term nursing and residential care for those who need them
9. ensuring that services supporting patient choice and control, with all the care and support required, are available towards the end of life

The tenth point is that all the others require integrated healthcare, bringing together medical, nursing and social care, in hospitals, family practices and community settings. An integrated approach sees a patient as a whole, not as the vehicle of a single medical condition, or even several. It accentuates quality of life and does everything to maximise choice and independence. Such care would certainly be the best imaginable.  What may seem paradoxical, but isn’t, is that is also likely to be the least expensive. That’s because it minimises healthcare demand and shifts as much as it can to less costly settings, in particular away from the acute hospital.

This approach will have benefits far beyond care for elderly patients. As the King’s Fund argues:

The balance of evidence is clear that integration can improve people’s experience and outcomes of care, and deliver greater efficiencies… It is important to recognise that achieving improvements for older people will also positively affect care for the rest of the population. More effective urgent care and post-acute rehabilitation and re-ablement services are important for people of all ages, while reducing inappropriate care and shortening acute lengths of stay for older people could release resources to meet other needs.

Avoiding the avoidable and coordinating care more effectively will deliver better care. Far from costing more, that may free up resources. So the ageing of the population may not be so much a crisis, as an opportunity.