Wednesday, 24 February 2010

Mid-Staffordshire NHS Trust

Many of you have probably already heard about the investigations and subsequent report that has suggested that several hundred more patients than predicted died in the Stafford Hospital emergency department between 2005 and 2008. The report also indicates that staff were uncaring and more focused on saving money than treating patients.

Whilst I do not in any way condone the treatment of these patients I dont blame the nurses or doctors at this trust. They became EXACTLY what the NHS is training us to be. If a patient comes in to A&E we have a four hour breach target. So if the patient is still present on the department four hours after first being seen by a triage nurse the department recieves a fine to its next budget. You have four hours to fully investigate a patient .It can take longer to get blood test results back or find a radiographer to take an xray for you. Add to this the fact you see a lot of the same patients every week who "cry wolf" if you have to save time and money for your department(money that may well be used to pay you) the temptation may be to discharge the same old patients without a complete investigation(I promise you that will be the time they are actually ill).

You then have cost limits on treatment, if a patient needs a dressing we are told to use the cheapest dressings available that are not likely to get the trust or practitioner sued for malpractice. For example if you have a deep pre-tibial lasceration(a deep cut to your shin) we will have to chose a non adhesive layer to prevent the top layer of gauze sticking to the wound bed, realistically there are three options -

1. Release - A sort of thin gauze covered in some kind of oil to prevent it sticking. The oily layer dries within a few hours and the release then becomes stuck to the wound bed, to remove you have to soak the dressing in saline and if you are very very lucky you wont reopen the wound. Very Cheap.

2. Atraumen - A greasy mesh that stays non-adhesive for about three days(at which point the wound should be assessed anyway), doesnt do a bad job. Moderately Expensive.

3. Mepitel - A silicone based mesh that I have never known to dry out while covering a wound, can be used for upto about 18 depending on trust policy. Primarily designed for burns but still incredibly effective as a general non-adhesive, can also be used to draw a wound together in the absence of steri-strips. Does an unparalleled job. Fairly Expensive.

In my trust we are told never to use mepitel and we can only use atraumen if a senior doctor has signed off on it. There is a similar system for anti-emetics(anti sickness drugs) we give cyclizine because its cheap, although it does make patients very light headed and dizzy. I would personally refuse anything except donperidone which does the same job but without the unpleasant and very common side effects.

Fortunately the hospital I work in completely ignores the targets set by people so far up the chain of command they dont even know what a hospital looks like. If we feel a patient is less likely to develop an infection because we have used mepitel we use mepitel, if a patient is clearly distressed by their nausea we will not give them cyclizine, knowing that the secondary effects of cyclizine will distress them further. And I can honestly say I have never discharged a patient without ensuring they have some help in place. Even if I dont believe what they say is wrong with them and they came to us instead of their GP I will phone their gp and make an appointment for them knowing I havent just left them out on their own.

What has happened in Staffordshire is tragic but it is the result of government and NHS target setting and the threat of penalties to any trusts that dont meet these unrealistic targets generated by people who either have no clinical experience or had it so long ago operating theaters floors were still covered in sawdust. The new chief executive of this trust has already proven a massive improvement in care since hiring close to 200 extra nurses.

As a side note if I were to become ill this is now the trust I would want to go to. Given the scrutiny this trust is under it will probably be demonstrating exceptional standards of care for some time, whereas many other hospitals which receive good marks have probably grown complacent.


Hogday said...

Interesting stuff. Your final para reminded me of what I was once told, that the safest place in town to eat is usually the restaurant that's just re-opened following its prior closure under public health regs.

Asclepius said...

Not my best constructed of posts. I have to admit to being a bit angry that all this blame is being put on the clinical staff when they are only at fault because they didnt break the rules handed down to them by their masters. Admittedly this led to them breaking the first and most ethically binding vow a qualified doctor will ever make and as for the nurses the NMC code of professional conduct should supersede any local or other government policy.

Hogday - I agree with that statement with only one exception, a restaurant in a local city is closed about once a month, re-opens and then closes again.