Monday, 5 January 2015

It's raining risk!

In all the current fuss over overloaded A&E and dire GP recruitment and the endless recycling of blame, there is one bedrock of reality that the press and politicians alike do not appear to be aware of, let alone understand. This reality has not always been well articulated by medics This reality is clinical risk and it drives everything the NHS does.
I want to develop a climate analogy which I hope will illustrate the above but first what do I mean by clinical risk?
As soon as someone develops symptoms, questions of clinical risk arise. Most manage those questions themselves - 'It's just my usual headache.' Maybe or maybe it's serious. 'I'll wait and see; I'm sure it's nothing' they manage it within their social setting. But once that capacity has been exhausted or (?over) sensitised by some health campaign, it presents to the health system.
Clinical general practice consists of making 100's of decisions daily concerning that risk.
Eg I get a phone message via reception that a patient requests more of those painkillers another doctor gave two weeks ago. So do I prescribe with potential risks of missing something and of inducing prescribed opiate dependence? Or do I trust the patient's judgement about re-consulting? I could see him/her but without it adding anything useful and in the process create an opportunity risk for the next patient who was then unable to see me in that slot.
The point is this; this clinical risk HAS to be handled and the buck has to stop somewhere. If I prevaricate and push it around the system I merely generate more health cost and new risks. So many of the simplistic solutions on offer fail at this point.
For some risks the course is clear: a new inguinal hernia needs sending down stream to the surgeon who will absorb the clinical risk by repair. But, and this is where the palpable ignorance of much of the media is, well, palpable, 95% of the risks do not have clear referral pathways because the risk defies neat diagnosis. There isn't anywhere better for them to go other than the risk sink that is primary care, mediated through safety netting, time, judgement, some interventions and, crucially, trust. Send them elsewhere and you waste resources. But medicine is complex and decisions are not always obvious and the triggers to a different course can be subtle, which is why it takes 10 years to train a GP and few more before they feel really confident.
So to the climate analogy. Primary care is the hills, forests, moors and upper river valleys. The risk falls as rain. If it is not to wash away bridges and wreck downstream A&E departments, (The clue is in the title: it's for Acute & Exceptional risk) it mostly needs to be contained early on and some of it channelled in a controlled fashion to the hospital department rivers that take the risk safely out to sea.
So we must have effective risk sinks for the safety of the whole system.
We cannot replace risk soak-aways entirely with risk-proof surfaces like medical assistants or inexperienced nurses and there is a limit to the risk absorption individual GPs can manage. Each decision takes finite time and taps emotional energy. Even with folk helping you, someone still needs to take responsibility for the risk handling decisions. The current crisis indicates that capacity has been exceeded.
The climate is changing and it is getting risk wetter as the population ages, some are becoming poorer and others seed the clouds. Our current problems cannot be solved by improved access alone if it is not accompanied by effective risk management.
The issue of GP pay is in many cases already irrelevant, as the personal cost is too high at any price. Too many have signed off with 'It got too much'. Yet the myth of the GP pay deal has remarkable traction despite being over 10 years old. Even the most brazen of politicians rarely try to blame a current crisis on the last but one government! It's hard to see how more resource can be avoided, even if actual pay remains static, (assuming one actually wants to solve the problem) despite the hypocrisy of portraying wage rises in the private sector as a sign of economic success and those in the public sector as symptoms of system failure. In any case we desperately need to reinforce those upstream defences.
This analogy highlights the blind stupidity of only focussing on A&E and hospitals. And yes we also need to dredge channels silted up with outdated modes of working (and market driven transaction costs?)
We (Politicians are you listening too?) must develop our first line of defence: empowering people's own risk management. This discussion must be had. For politicians to walk away from this is a dereliction of duty, Mr Hunt.
We need to ask of any health campaign what its effects on the climate will be and if it can't prove short term risk reduction, forget it. Will it really reduce risk rain in future or merely overload the system now?
We need OOH and NHS 111 to function as better risk soak-aways and not just channel it all downstream.
Until the crisis passes, we need to redirect activity upstream toward risk management and drop other risk generating activity such as dementia screens and health checks (even if they had been well conceived).
Our downstream NHS resources have been designed on the assumption of risk sinks higher up: and these are being lost...
Global warming is happening in this analogy and the flood prevention solutions are similar to the physical world, as are the consequences of inaction.


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