The blue lights flashed across the night sky, the amber street lamps reflecting on the wet road.
Patrick swung the Sprinter 515 through the gates and into the floodlit bay at the business end of A&E.
There was a time when the detectors would have picked him up and flooded the bay with light. These days the Luceco 50Ws are on all the time; illuminating twelve other ambulances parked, waiting to pass their patients into the care of the hospital.
Patrick groaned... he could be in for a two hour wait. This was becoming routine. All thoughts of the 15 minute hand-over target, gone. Delayed handovers are up by 70%.
Hospitals don't have elastic sides. When they are full they are full. No one can seem to account for the huge increase in A&E admissions. The weather, an ageing population, abuse-use, failings in primary care, care homes not coping with the shift in acuity amongst their residents, relatives gone to lead busy lives elsewhere; whatever it is, it is crippling the system.
This is not a Rubik puzzle; if you can't get them out of the back-door, you can't bring them in through the front door. Simple.
Hundreds, probably thousands of beds occupied with people medically fit to go home but marooned until skeleton social services can play their part, Better Care organisers get better organised, and care homes respond to the changing profile of their residents.
The solution? A shed load more money might help. Don't hold your breath. Hosptials taking over a 'vertical responsibility' for social care? It'll happen but not soon enough.
The main patient group, blue-lighted to hospital, but difficult to discharge is well know; elderly and frail. The longer they are in hospital the faster their sharpness is blunted.
Is there a way out? There is no silver bullet but there might be some silver buckshot.
ECIST have a set of simple rules. Five key elements they call SAFER for keeping the system moving:
S- Senior review, by a consultant, before mid-day;
A - All patients to have an Expected Discharge Date;
F - Flow of patients will commence at the earliest opportunity (by 10am) from assessment units to inpatient wards;
E- Early discharge, 33% of patients will be discharged from inpatient wards before midday. Medication to take home, for planned discharges, should be prescribed and with pharmacy by 3pm the day prior. If not, prepared in real time, never leaving them to later in the day;
R - Review, weekly systematic... by clinical and social care leaders, of patients with extended lengths of stay (>14 days) to identify issues and actions to facilitate discharge. Operational managers to remove constraints that lead to delays.
Of course stopping patients, known to be vulnerable, ending up stranded in the system is the best idea. A team from Dorset County Hospital came up with a hospital at home scheme that saved eight bed-days, a day, for the Trust. Multiply that by 150 Trusts!
Airdale has an innovative care home model to prevent admissions. There are 6 Vanguard sites working in the same space.
The Brighton and Hove CCG turned the system on its head; they got the voluntary sector and adult social care working like a Swiss watch, discharge patients and then assess them in their own home. Wow!
They find levels of acuity are higher in familiar surroundings. There's a video here, must watch. Another video is here, from Coastal West Sussex, with a similar approach.
These are ideas that work. They are not nuclear but they do put a bomb under our thinking. They don't shift tectonic plates but they do move patients through the system. They are not top down targets but they are right on the mark.
You'll never 'inspect' them into the system but you might just look over someone's shoulder and learn.
They don't involve fines, penalties or calling people names for 'failing'. They involve little, vital details, found and fixed by the front-line.
People working together, today, being innovative, learning from each other energizes us all for tomorrow.
To be great at doing the little things is truly heroic perhaps even noble. Without the little things we cannot achieve the big things.
Show people what good looks like and they'll get on and do it.... better.
Have a good weekend.
All today's references and more of 'what good looks like' can be found on the
