I’m back again after not writing my weekly diary for the last 3 weeks.  This was due to a mixture of taking some time off over the holidays and of being extremely busy on the days when I was working.

 

Winter Pressures

Over the holiday period the winter pressures arrived with a vengeance and my clinical sessions in the AMU have been incredibly busy.

The current AMU setup at the RVH in Belfast is relatively new and came about in response to a widely publicised crisis situation with unacceptable 4-hour and 12-hour breaches that created an overwhelming driver for change to improve unscheduled care in the Trust.

This new AMU setup has brought some early success with improved performance against the targets which in turn led to the Minister relaxing the special measures on the Trust in November.  However, it is increasingly evident that there is a limit to what can be achieved solely by improving the unscheduled care service in the acute hospitals.

Over the past number of weeks the rate of admissions to acute medicine has been relentless and has not been matched by the rate of patients leaving the unit through discharges, transfers and specialty triage.  A new ‘Virtual Ward’ run by the AMU team has helped by providing a safety net that allows early discharge and expedited investigations.  This has been a success in terms of patient outcomes, patient satisfaction and bed days saved, but still we ended up with a full 63-bedded AMU and a significant number of outliers.  Of course a holiday period flanked by weekends didn’t do anything to help but there appear to be real problems upstream and downstream from the ED and AMU.

Upstream – some patients present to the acute hospital because there is no suitable, safe alternative in the community.  Until this changes acute hospitals will continue to be under pressure with large numbers of admissions.

Downstream – unless pressure is felt downstream from the AMU where is the impetus for other specialties to innovate and improve the efficiency of their services?  And what about discharge options – we need fast, responsive, safe community services so we have somewhere to confidently discharge patients to.

For anyone wishing to gain a better understanding of the complex system issues related to unscheduled care i suggest you read the recent weekly diaries of Dr Mark Newbold, CEO of Heart of England FT.

The Transforming Your Care Review in Northern Ireland has a major focus on moving care closer to home, and shifting care from the acute sector to the community.  This gives me some hope that the system-wide issues affecting unscheduled care in NI will improve in the near future, but the figure of £70m mentioned as transitional funding doesn’t sound substantial enough and I hope funding issues don’t hamper much needed change.

 

Staffing Problems

This week I was contacted by a Trust seeking urgent help with a staffing shortage at Registrar/Middle Grade level come changeover in February.  I met with the Consultant who oversees the rota to learn about the problem, what staff they do have available, the nature of their service, the peaks and troughs in demand, and what other tiers of cover and sources of support they have.  I could see from the outset that this is one of the most challenging staffing dilemmas I have been asked to assist with in a while so I’ve set time aside early next week to go over the data supplied and see if I can come up with a safe and sustainable staffing model with contractually and legislatively compliant working patterns for the doctors involved.

There is an interesting and important phenomenon is medicine.  Once a service or specialty experiences a degree of staff shortage that impacts on the working lives of the staff and leads to the work environment becoming pressured and overly stressful the vacancy rate goes up as staff resign, move elsewhere, change specialty, or don’t apply for the specialty in the first place.  A vicious cycle ensues that is very hard to break.  Hence it is essential to listen to staff concerns and address vacancies and workload issues expeditiously.  This approach is not only cheaper in the long run, but it’s better for patients and staff.