I work in a small, not too busy, Rural Hospital. It is clean spacious and has excellent staff. In business-like terms, the structure and processes compare with the local fish farm – still medieval and relying on the transmission of information by paper or paper to computer to paper.
On the computer, there is a myriad of IT systems to search to try to find crucial information like the result of an MRI scan done 2 weeks ago in a hospital 70 miles away.
At times we have no information.
Recently I was ‘in charge’ of a middle-aged patient visiting from England who looked horribly ill and vomiting copiously. The patient had received treatment for cancer with metastases to the brain. The last treatment was 6 months before, or so the patient’s partner told us.
We had no access at that moment to any reliable information about the underlying clinical diagnosis, what treatments had been used, or the prognosis. Even now we don’t have the information, because NHS England and NHS Scotland information systems don’t join up.
Fly return from London to Glasgow with Easyjet and somehow miraculously when you turn up at Glasgow for the return flight both Easyjet and the airport are expecting you and hold all your details, you show your unique identifier (passport or driving licence) and away you go.
Travel from London to Glasgow with a complex or even simple medical condition, fall unexpectedly ill and the staff in A&E in Glasgow (or Oban) know nothing about you (even your address), nothing about your diagnoses, medications, treatments, results, prognosis – nothing.
The NHS has abandoned your health to your recalled memories.
When you are ill, especially if you are unconscious, memory is not too reliable, and the NHS has failed in its policy to provide you with copies of all correspondence. Even if you had the copies, you would probably have left them at home because you naively assumed the NHS was perhaps more efficient and organised than Easyjet, because the NHS claims “You are safe in our hands”.
We needed to know for this patient “Was the treatment finished and the patient for Palliative Care or finished because of cure?”
Of course, in the absence of information we then treated the patient aggressively and the next day the patient was just fine. The diagnosis turned out to be viral gastroenteritis causing vomiting in a person with a history of metastatic cancer. The patient then told us the treatment had been some new wonder drug that had worked well in that patient’s case. But in NHS Scotland we have no access to information on patients in NHS England. The unique identifiers NHS and CHI number are different making transaction of data even more difficult.
If we can manage to identify the person’s GP (remember we know nothing) it can take an age to get the Practice to answer the phone and then to agree to Fax the information to us. Mostly staff just don’t even try to contact the GP. Also, when we Discharge the patient, we cannot send the summary to the GP in England because our Patient Administration System (PAS) does not list GPs in England and actively blocks typing in the GP’s name, address and Practice email account. We hand over a paper copy of the Summary to the patient and hope the patient gives it to the GP back in England.
The point is that the NHS is so used to being decades behind where we should be that we don’t see how dreadfully weak and inefficient the processes are.
We have drifted into failure and now what is ordinary is taken as acceptable.
On Thursday I nearly gave up on trying to see a chest xray, because the one available PC on that ward took 10 minutes to let me logon, boot up and find the CXR. I asked for that PC to be replaced months ago.
Remember Dr Bawa Garba was criticised for not reviewing an X-ray in a timely manner. I know that if it took 10 minutes to boot the PC to review Jack Adcock’s CXR, she would probably have been interrupted 5 to 10 times by staff asking her questions.
Our minds should be on the patient, the diagnosis, treatment, monitoring and review. As we use NHS IT systems, a toxic mix of paper and computer information systems, our brains become like the Paul Simon song: “My mind’s distracted and diffuse, my thoughts are many miles away”.
Our brain’s RAM is fully loaded just with manipulating the information systems, making phone calls, filling forms and writing ‘To-Do’ lists that need updating every 15 minutes, then we misplace the list and cannot find it.
If you are ever interrupted and afterwards have to ask yourself “Now what was I doing?” then at the time of the interruption, your brain was overloaded.
I have just seen holidaymakers wandering around Morrison’s car park trying to find their car. Their brains had been overloaded with shopping lists, the beauty of Ben Nevis, the route to Glen Nevis and talking about Brexit and they had forgotten where they were.
A Doctor’s brain is as easy to overload as a holiday maker’s, so don’t overload it with having to wrangle with information systems, with too much work, too many interruptions, too much rewriting or known information, too many forms to fill, phone numbers impossible to find, especially when dealing with an unwell child.
The environment should be library quiet, palpably calm and no sense of disorganisation and chaos.
Then the Doctor and Nurse can give full attention to the child, not to everything else.
There is constant noise and interruptions even in our small hospital. We too wrangle with information systems. The computers on wheels we need to have at the patientside have not worked reliably for the 15 months I have been here. Even if they can be made to work it is a labyrinth of information systems to negotiate to find e.g. the CXR done 10 minutes ago. Actually, we are not even allowed to see the CXR on the laptops.
And we are a quiet unit compared with where Hadiza Bawa Garba and Isabel Amaro were working.
Even the best of Doctors and Nurses will sometimes make lethal mistakes under these circumstances.
If there must be the Crime of Gross Negligence Manslaughter (there is no such crime in Scotland) then the people charged should have been Corporate Leaders who should be accountable for how the business-like processes of Illness-Care operate, not the individuals struggling in Medieval processes.
So, if we must have the crime of Gross Negligence Manslaughter, then it should have been the CEO, Medical Director, Director of Nursing, Director of IT, Director of Imaging, Director of Pathology etc in the dock to see if the corporation of the Hospital was guilty of running grossly negligent processes.
Recently the owner and maintenance manager of a truck company, not the driver, were found guilty after a child was killed and the truck had not been maintained in a road worthy state. In comparison to other country’s healthcare systems, we are inferior. We don’t rank near the top, and the main reason, in my opinion, is that our Structure and Process are so out of date for the Intranet Age.
If in our country, we tolerate badly maintained cars and only had single track unsurfaced roads, crowded with traffic and no rules of the road, when the resources were there (£16 billion spent on NHS IT in the 2000s) to build motorways, develop driving instructors, enforce innovations like seat belts and antilock brakes but this was not done, and there is an accident and passengers injured, would it have been fully the driver’s responsibility?
And what if the passengers had been noisy, arguing and constantly interrupting the driver? And if the driver had to login to the speedometer, and separately into the fuel gauge, the windscreen wipers and indicators and by the time the driver needed to turn right found the engine had cut out and needed to login to the ignition again?
Last year I came within a hairbreadth of not giving antibiotics to an 18 months old before a two-hour ambulance transfer to Glasgow. I was new to the hospital, new to the team, new to seeing unwell children, new to the IT systems, new to “How to refer a sick child to Glasgow”. The child later turned out to have meningococcal septicaemia (more lethal than meningococcal meningitis). Without the antibiotics, the child would probably have died or been severely brain-damaged. I was concentrating on the child’s unexplained hypoglycaemia, but also having to make phone calls to ambulance control, trying to contact Paediatrics to accept the child, I was tired after a full day’s work and already been on duty 14 hours, I was working with a Junior Doctor new to the team, alarms were sounding, interruptions, other ill patients, multiple request forms to fill by hand, incoming phone calls etc. I could not give the child’s problem my full attention, could not get a moment to step back to gather my thoughts, could not hear myself think. Fortunately, the Junior asked “Should we give some antibiotics, even though the PEWS doesn’t score for Sepsis6?”, we asked Glasgow Paediatrics, who had also been concentrating only on the low glucose. A powerful antibiotic was given and the outcome was good.
For me the lesson of Jack Adcock is that we frontline staff are working in a frontline that looks neat and tidy but intellectually is like being in a World War One trench and supplied only with a pitchfork, not even a rusty musket, to defend from and attack the enemy of the illnesses progressing relentlessly in time in our cohort of patients (You are aware of how many patients were in Dr Bawa Garba’s cohort?). I was struggling with just one unwell child and there was a GP and a Junior with me and 2 or 3 experienced nurses.
Everyone knows we are understaffed at the frontline. If we are understaffed, then every supporting system and process must be super-slick not super-treacly.
If we have to use our RAM to wrangle the information we need and to fill in the requests etc, then the RAM is not being used on diagnosis, treatment and review of progress.
That’s why this case must be overturned because it was the incorrect people in the dock. We must frighten the pants off Executive Teams and open their eyes to the dangerous workplace systems and get them engaged in an information revolution that supplies us with the information we need for safe decisions making and releases our brains to be able to stop, think and take control of the situation rather than be in constant emergency and reaction mode.
The big danger, however, is that once the Executive Team has had their pants frightened off them, they will just enforce off-the-shelf systems without ever visiting and getting a deep understanding of the processes of care.
In the Mayo Clinic services in the USA, the Top Team Members all still work 2 days a week in frontline care. They too have to wrangle with the daily processes, they know whether they work and how much they need to be improved.
In the NHS Medical Directors and Directors of Nursing rarely do any clinical work. For example, in my previous Hospital I believe we had the new ePrescribing Process and eHealthRecord systems rolled out, without the clinical members of the executive team even having used a pilot version, let alone try to use the systems real-time on Ward Rounds on the computers on wheels that were not supplied to Doctors as part of the project.
If our mind is elsewhere it is not on the patient.
Even the best Doctor is capable of lethal mistakes under these circumstances.