When systems meet people… and people meet systems

This is going to be a long post, because it’s something that I’ve been mulling over for a while.

I’ve been thinking a lot recently about systems, and the impact that they have on people in the NHS.  Is this stating the obvious? After all, we know it’s a system.  My feeling over the past week has been that most of the conversations about the NHS (and particularly about its failings) focus at the wrong level.  There’s a tendency to discuss “the NHS” as a single entity; even when we talk about it at a local level, it’s about Trusts, hospitals, departments.  Sometimes, we hear about individual patient experiences.  Even with the amazing work that Martin Bromiley and the Clinical Human Factors Group are doing, it seems to me that we rarely look at how systems work at a “people” level.  (I’m sorry if I’m missing official terminology; these are just my personal reflections).

What do I mean by this level of systems working?  One example is when patients are referred to a clinical team from A&E, which means that patient should be transferred out of the department.  Accepting a patient who’s unwell onto an admissions unit can mean using the entire nursing & medical capacity to manage them safely; there’s a delay for other patients.  Accepting a well child with measles takes up a space that could be used for a baby, but provides reassurance & is an important safety-netting opportunity.  But the tendency is to talk about % of admissions and net increases in referrals.

I think this focus on the individual or the high-level system does us all a disservice; because we don’t explore things at this level, it’s poorly understood by those who are most affected.  Patients are left feeling that we don’t care.  Staff are described as uncaring, lacking compassion, and deliberately denying care to patients (taken directly from a recent Twitter feed).  Complaints through PALS look at individual issues; incident reports may pick up recurring problems, but again will usually look at a single issue.  But we work in complicated, interweaving networks; unless we understand this, how can we respond to the individual concerns in any meaningful and effective way?

It was a busy night on admissions, but we were getting through OK.  Then the bleep went off, and the speaker crackled “paediatric cardiac arrest team to resus. Paediatric cardiac arrest team to resus”.  I had just finished cannulating and was attaching the final dressing as the bleep went off.  I apologised, leaving the child with their father and a nurse.  “aren’t you going to stay and give him his antibiotics?”  “No. Your nurse will. I’m sorry, but I have to go”  I’m running down the corridor at full speed through admissions, collecting my team as I go.  One registrar, two SHOs, one nurse: parents and children move back and watch.  On the stairs down to A&E we’re joined by another nurse from intensive care.

We spend almost two hours in A&E.  

We fail.  We are failures. What is the point if we can’t even manage this?  I tell the juniors and the nurse from my team to go back upstairs; I ask them to get a coffee and go to the break room; I know they need time, but I cannot give them this.  Children, other children are waiting.

I go back to admissions.  Children are crying; everyone is tired; it’s well past everyone’s bedtime.  As I walk back onto the unit, a family approach me with a complaint.  They have been waiting for over two hours to be seen by a doctor.  They were there before we left; they cannot understand why there aren’t more doctors to see them.  I apologise.  I cannot explain.  I cannot speak. It’s not my place to share with them somebody else’s grief.

I pick up the next set of notes, and go to the next child.  The parents look at me; I tell them I’m sorry for the wait, that there was an emergency.  The father tells me he saw us leave, and asks if it was OK.  I say nothing, but it must be written on my face.  The mother looks down, then looks at her child.  I see a tear come into her eye.

And what happens next makes me weep.  I am weeping as I write this.  They ask me if I’m OK.  They ask me if I need a break, that they don’t mind waiting for 20 minutes for me to get a drink.  I take a deep breath; I’m fine I tell them.  What happened is nothing to do with them; it shouldn’t make any more difference to their care than it has done already.  For the patient, for that child, it’s already unacceptable that the wait has been extended so long.

For the rest of the shift, we all think about what has happened in our own ways.  I don’t know what to say to my juniors.  I think about the things that my seniors told me; I don’t think anything helps.

In between patients, my mind flashes back to what happened.  I duck into the treatment room; I time myself; if I take 120 seconds away, that’s not too bad is it?  But it’s another two minute wait for somebody; over the night, that’s maybe 10 minutes that I’ve delayed things.

We talk about the NHS as a huge behemoth system but that system is made up of individuals and it affects the individuals it serves in ways that we can’t measure and can’t begin to address.  I sometimes, often, wonder if I am right to spend so much time on social media; if engaging and discussing and sharing my views is the right thing to do.  I sometimes, often, wonder if I have the right to express these views; that I am in a position of power already; that I have my voice listened to anyway.

But I think I keep going.  Sharing experiences helps us understand how these networks work and the impact they have on all of us.  And without understanding, we cannot begin to to find solutions that will work and make the changes that we, all of us, need to happen in our health service.

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