Our Recent Experience of the NHS
We had a baby girl 2 months ago. It was our first and we were obviously a little nervous about what would happen and how. We live in Gloucestershire, an area where healthcare is really patchy and maternity care is pretty bad. There are only 3 NHS locations for births in the whole of Gloucestershire. I know that we could travel to a hospital outside of the county but that is 3 locations for 600,000+ people. Well. I say 3 locations but actually, more like 1 and a half.
The main units at Gloucestershire Royal Hospital are open 24/7. Well they aren’t, since the Midwife-led unit is often closed due to a lack of staff. Cheltenham is Midwife-led, which excludes a lot of first-time mothers or those with potential complications/caesarean births who need doctors to be available. It is also closed for refurbishment. Stroud is another that is Midwife-led but it is only open limited hours, mostly during the day since they don’t have enough staff to cover the ward overnight. In other words, everyone has to go to Gloucester or have a home birth, something that should be encouraged with what we now know about better outcomes, but again, something which is not an options for a good number of mothers.
We all know the NHS is struggling but we didn’t quite appreciate how much. However, when you are starting from a weak position, efficiency is everything right? If you have loads of staff twiddling thumbs, you can get away with doing whatever you feel like, but when you are short, all hours need to be effective, including things like rest breaks (we had one Midwife taking her “lunch” at 4pm). What we found with the experience wasn’t that the resources weren’t there, but that they were so poorly utilised.
A recent report from the Care and Quality Commission said that, “Many people are still not receiving the safe, good quality maternity care that they deserve, with issues around leadership, staffing and communication. Ingrained inequality and the impact on people from ethnic minority groups remains a key concern.”. We have also recently heard some horror stories from across the UK where it wasn’t so much minor mistakes or a 50/50 decision going the wrong way but terrible stories of babies dying due to a basic lack of care.
So what about the bureaucracy?
What I notice is that a lot of people are simply not proactive and intelligent/trained enough to be able to make their own decisions (that’s in general, not just in the NHS). So my wife was re-admitted after giving birth due to problems with blood pressure and extreme fatigue. We experienced a catalogue of problems that resulted in her having to be taken to a high-dependency room (with a 1 week old daughter) and me receiving a call from a mid-wife (i.e. why is a staff member calling me instead of my wife?) that all started when she went to hospital to get something for itching and being diagnosed with pre-eclampsia, a serious condition that can lead to seizure or stroke and although not understood, has to be monitored and usually accompanied by blood-pressure medication to reduce the chance of a problem until the birth eventually alleviates the unknown causes. That was all very well except she was prescribed a type of medication that reacts badly in Asthmatics, unknown to us but something that was affecting her for around 2 weeks until another doctor realised this and changed them. Really easy to get something like that correct…
Anyway, after being readmitted to the normal maternity ward, she was still on pain meds so when she was complaining of a severe headache, she was told about 4 times by 4 different members of staff that they were waiting for a doctor to prescribe something. Eventually, not getting any medication over the course of roughly 8 hours made her collapse and had to be taken to the high-dependency maternity ward where she had to have 1-on-1 care from a Mid-wife (how much is that costing?) for the want of a single doctor to be able to offer simple headache medication.
Why? Partly historical and partly bureaucractic right? In the old days, only Doctors could prescribe although now some trained nurse practitioners can also prescribe specific treatments. Even so, something as basic as pain medication shouldn’t need a doctor to sign-off on unless they are specific conditions that make it more dangerous. It seems like the most simple thing would be some specific pre-defined medication paths. Let’s not pretend that a doctor has enough time to treat everyone as bespoke, we know that they are likely to have a set of preferred meds they start with with maybe some reasons to choose one over another and then if they don’t work or don’t work well enough, they increase the dose or change it for something else. They cannot know what will definitely work and could easily define these and allow other qualified health staff (Midwives and nurses do have degrees!) to follow these paths. As the worst-case scenario, you allocate a doctor who isn’t doing the rounds who is always on-call for emergency medication decisions, they could even sit right next to the Nurses desk in the ward so thy are accessible.
But let’s say that we all agreed it was a good idea, how do we implement it? Well, of course, this is where the red-tape cuts in. How many people would need to agree that it would work and the exact nature of this new system? The nursing and midwifery staff would need to be on-boards, the doctors would also be. No doubt the Management would need to be involved and there might be compliance issues, issues with the medical colleges, insurance, you get the idea.
The truth is, changing bureacracy is very slow and very hard, which is why things don’t change very often and why in most places, it is far, far, easier just to do it the way you always did it than have good ideas.
It’s not just healthcare
We heard about some medical devices that the Maternity ward bought (I can’t remember what for exactly) but the rules are that they need to be signed off by the Medical Engineering Team before use. They stayed in a cupboard for 3 months before this was done. £1000s of money and something that they needed to do their job but because of some tickbox, they couldn’t. Again, easy solve. What are you signing off exactly? If you need things like compliances and insurances, they should already be in-place for your suppliers before stuff is ordered. If they are electrical tests, I can assure you that the supplier has to carry out a lot more tests than you would carry out in a hospital.
A midwife also told us about other equipment that took so long to be approved, it was no longer suitable afterwards and had to be thrown.
Why do we do it?
There is a very simple explanation for why we do it. Bureaucracy is a convenient way of implementing improvements, even if it doesn’t actually work that well. What happens if a baby dies in the midwife unit? All-together now “We have looked into the underlying issues so that lessons can be learned to avoid the same mistake…”. Except of course, it doesn’t. What it leads to is another form, another system, another counter-signature, it leads to lower productivity since it seems reasonable that another check would prevent the problem. Except it doesn’t because most problems are caused by people not following the process properly. Maybe they weren’t trained, maybe they forgot that part, maybe the forms were all run out or the photocopier/iPad etc. was broken, maybe it was a cover member of staff who was not familiar with the hospital but was covering sickness. Maybe, just maybe, there is so much paperwork and nonsense to do that the staff don’t have the luxury of spending time with the patients, understanding them and helping them through a very stressful time.
The hidden cost of this is a system that becomes not only less and less efficient over time (as the suggested cost of the better quality) and becomes a monster that cannot easily be defeated. Who ever says that we can get rid of that signature we added due to a baby death, who says we should junk that £1M computer system to manage blood pressure readings etc.? No-one because no-one knows what will break when the system gets modified later. What else relied on that thing?
This is partly on us as a society. We used to have a time when the Doctor was king and their word was law. When things went wrong, it was tough luck (even if the Doctor was incompetent). Now we want full transparency, full accountability, second-opinions on everything and everything double-checked twice. I suspect if we had a system that was much more agile in its management, something that professionals were allowed some flexibility in, maybe we wouldn’t have 1000s of people leaving the NHS and leaving the remainder with even more work to do?