Tuesday, April 24, 2007

The British hospital experience

Notes from a patient -- Prof. Brignell. He got prompt treatment only because he had private insurance but even then the NHS did not make it easy

Kafkaesque! That is the word. If you don't know what it means, make an appointment as an outpatient with the British National Health Service. An hour or two in the waiting room is enough to induce that feeling of hopelessness endured by Joseph K. In my case they had taken the trouble to write, bringing the appointment forward by half an hour, but I was still there in suspended animation an hour later than the original appointed time. About fifty assorted human beings sat glum and dispirited, some occasionally whispering to each other with a librarian reverence. In the background, people in various shades of uniform bustled through unseeing, intent on their business. Behind the reception desk women rattled computer keyboards with intense determination.

Suddenly my name was called and I found myself whisked from the large waiting room to a small waiting room. There was no silence here. A very large Irish woman was regaling the reluctant company with an account of her recent experiences as an inmate, including details of biological functions we would rather not know about. After another half hour, a woman approached me and said "The registrar has looked at your notes and has decided to let you see the consultant." Perhaps welcome news, except that it was the consultant who had asked me to come back and see him ten weeks after the first examination. People came and went. I waited.

It was quite different once I penetrated the inner sanctum. The consultant was urbane and gentlemanly, radiating that cultivated assurance that we used to expect of our medical advisors. He recommended that I have a course of intravenous antibiotics, but we would have to wait for a hospital appointment, as it should commence under observation in case there were any reactions. I mentioned that I had managed to retain sufficient medical insurance to cover hospital admission, so he left it with me to make the appointment. When I phoned BUPA there were no problems and a bed was found for me for the following weekend.

The difference! When you approach the NHS hospital, the first thing you see is a large yellow notice with ominous black capitals announcing THIS IS A WHEEL-CLAMPING ZONE. Just the thing for people in distress and pain, who have to grope around to see if they have the coins to feed the meter! It induces the same sort of anxiety as a notice I remember from almost forty years before YOU ARE NOW ENTERING THE GERMAN DEMOCRATIC REPUBLIC. The notice at the entrance of the private hospital said "Welcome" and directed you to the car park. Inside, the atmosphere was calm and kindly. What was striking was the obsessive hygiene and asepsis, from another age. Inside and outside each patient's door were dispensers for alcoholic hand rubs, which visitors were encouraged to use. Despite the occasional puncturing it was actually a pleasurable experience.

My local GP practice had volunteered to carry on the injections, so the consultant had arranged that I would pick up the antibiotics at the town pharmacy and take them in. I received a phone call to say that the pharmacy had discovered that it was not licensed to handle those particular antibiotics and would I drive back to the hospital pharmacy (a three hour round trip) to pick them up? Five days of injections went smoothly, but hanging over me was that threat of the unknown - THE WEEKEND. Don't worry, I was told, just phone one of these numbers and arrange an appointment with the out-of -hours service and we will give you the kit of parts to take with you.

Hello, is that the out-of-hours service?


I would like to make an appointment for some intravenous injections.

How did you get this number?

I was given two numbers and the first one did not work.

This is an administration number, you are not supposed to have it.

What would happen if I had used the other number?

It would come to the same place, but that is not the point.

I would like to make an appointment for some intravenous injections.

Well you can't. The system does not work like that. You will have to phone on the day.

I went back to the local surgery and the receptionist kindly arranged the appointments for the Saturday and Sunday. Fortunately, the appointments were in nearby Shaftesbury, at a local cottage hospital of the sort that the Government is trying to close. It was charming and, above all, clean, even having a hand-rub dispenser on the waiting room wall.

The professional staff were kindly and efficient, indeed magnificent. This is not just a ritual nod of politeness. These people, fully aware that they are working in a mad system, still manage to maintain and integrity and dedication that is a wonder to behold. As the intravenous injections are a slow business, there was an opportunity for conversation, during which I elicited some interesting remarks:

Reorganisation is the norm in the NHS.

The rules change so often that nobody actually knows what they are.

The trouble with the big hospitals is that the cleaners are no longer part of the team, as they were in matron's day, and anyway they can barely communicate in English.

Some patients get no treatment at all in Tasmanian public hospitals

ONE in seven patients leaves the stretched Royal Hobart Hospital emergency department before being treated because of long waits. Between December and March, 13,058 patients presented to the department but 1821 -- an average 15 a day -- did not to wait to see a doctor. Some of the patients had been assessed as suffering "life-threatening" or "potentially life-threatening" illnesses or injuries and severe pain.

But department director Tony Lawler said the "majority" were patients who had presented to triage with "potentially serious" or "less urgent" conditions. He said there was always a "concern" that patients who did not wait would die, but stressed they were encouraged to stay or given options for medical help. "We don't put people in the waiting room and forget them," Dr Lawler said. "We try to maintain supervision." [Hard to do when they have walked out!]

RHH chief executive Craig White said the "did not wait" figures were steadily climbing but the hospital was working hard to bring them down. The figures come as the emergency department -- which moved into its new $15.4 million home last month -- comes under increasing pressure and criticism. In the past month, nurses, patients, politicians and ambulance officers have complained of long waits for medical help. Ambulances have been "ramping" or building up at the department, unable to offload patients because the hospital is full. And an elderly woman died in the emergency department last month after four days trying to get help and hours in waiting rooms.

Dr Lawler said patients were prioritised on clinical need, sometimes causing frustration. "Sometimes a patient might not appear to be very ill," he said. "It sometimes seems there's an inequitable process about who is seen first." He said some patients felt better and left or decided to see their GP, but conceded some patients who left were rated category one, two and three.

Dr White said waits had increased because more patients were presenting to emergency and beds in wards were harder to access. He said access block was "complex" but recent nursing-home closures meant aged-care patients were taking up 16 beds. Access block figures from the second half of 2006 show 29 per cent of patients admitted through the RHH emergency department wait more than eight hours for a ward bed. This compares with a 27.4 per cent national average.

Dr Lawler said the hospital had started holding daily bed management meetings to free up beds and new systems would help ease the wait. The new emergency department allows patients to be "streamed" through three paths and there is a clinic dedicated to patients in the lowest categories. This means a patient needing stitches can be "in and out" without having to wait for a cubicle. A short-stay unit will open in July for patients who require observation but don't need to be admitted. Dr Lawler said this area would act as a "pressure valve" to the department and reduce waits.

He could not compare the RHH "did not wait" figures to other hospitals but Australian Nursing Federation state secretary Neroli Ellis said they seemed "high". She attributed the figures to the closure of 1B North, a 30-bed ward closed for six months for renovations that only began last month. Ms Ellis said up to 16 patients stayed in the emergency department overnight on trolleys waiting for a bed.



For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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