Ken is lying on the sofa. He’s only just got up and is still a little tousled in his PJs, but despite all that, he’s as bright and poised as any of the paintings or ceramics that surround him. “Thank you so much for coming,” he says. “I’m sorry to be a pain.”
Ken is 62, still in full-time work, goes to yoga classes and on trips abroad. He is perfectly independent. This has been a bad week, though. His sciatica has flared up and put him out of commission again. His doctor has referred him to us, the rapid response team.
“Physiotherapy sorted me out last time,” he says, folding his arms. “I expect that’s what I need now.” I agree with him, but say that every new patient we see has to go through an initial assessment and basic health screen first.
As an assistant practitioner with rapid response, it’s my job to conduct the screen, including blood pressure, temperature, blood sugar and pulse, urinalysis, an assessment of his risk of pressure area damage, his nutritional state, bowel habits, and then an ECG and bloods if required.
I’m sorry to have to bother him with it all. I tell him I’ll do my best to shimmy through the paperwork as quickly as I can. “But it’s my back,” he says. “Couldn’t I just see a physio? Don’t you have them on your team?” We do, I tell him, and hand him a leaflet which he reads while I work.
The rapid response team was devolved from community health services five years ago, aimed at reducing bed-blocking and inappropriate hospital admission. An acute, three-day service, it’s made up of occupational and physiotherapists, nurses, assistant practitioners, care assistants – all the frontline staff needed to help keep a patient at home and out of hospital. We have pharmacists to review medications, mental health nurses and social workers, and access to equipment providers for everything a patient might need.
The majority of our patients are elderly. They suffer from a variety of problems, but their situation can often be characterised quite neatly with yet another health service acronym: NCH (not coping at home). We take referrals from GPs, ambulance crews, community health workers and the hospital, and after three days the patient will either be discharged from us to a community bed, longer-term care provider, or to live independently again.
Unfortunately, that three-day limit can extend indefinitely, depending on availability. A few of our patients have been on the books for months. We do our best to move things along – there are consequences for delays – but sometimes there is nothing we can do, and the same names come around at morning handover.
Increasingly we find mixed in with the clear-cut cases some that are as bewildering as Ken’s. A fit company director of 52, finding it difficult to get upstairs with a temporary knee brace. A 70-year-old with full mental capacity, living independently with some family support, but who doesn’t want to take his type 2 diabetic medication. A 54-year-old alcoholic with a sprained ankle. But whatever we think of the referral, each one will get a full assessment and health screen, a case discussion and the formulation of a plan. When they are discharged, they will need processing by the admin team, and filing.
Everyone on the team wants each patient to get the best possible care, and I don’t doubt that’s true of clinicians higher up the chain, but sometimes I think that a fear of litigation is the real driver behind some of these referrals.
Litigation is a serious problem. According to the NHS Litigation Authority, the NHS in England paid out over £1.1bn in 2014-15 to lawyers and patients, with the figure set to rise to £1.4bn in the coming year. Alongside operating costs for the NHSLA of £2.6bn, the problem is severe and getting worse. An attempt to curb disproportionately large legal bills may dampen things down, but year-on-year the upward trend is set to continue.
Not quite so easily represented on a graph, but still of equal significance, are the below-the-line costs that thrive in the febrile atmosphere of risk aversion. The paperwork that mutates into bureaucratic form-filling, less to do with clinical communication and more to do with insulating the practitioner from the chill of the court room; the referrals that degenerate into an NHS version of pass the parcel (where the aim is not to be left holding the patient when the music stops).
Like any other service operating in primary care, the rapid response team does its best to navigate these pressures, struggling to maintain a workaday buffer between GP surgeries, the ambulance service and A&E departments. But when the workload is increased with inappropriate referrals and pointless form-filling, patients receive a more diluted service. Ironically, I would argue that a culture of risk aversion means mistakes are more – not less – likely to be made.
Back at the hospital in the offices of the rapid response team I hand over my patients to the coordinator. “I don’t understand this one,” I say, moving on to Ken. “A fit 62-year-old with a recurrence of sciatic back pain. The doctor’s obviously not worried it’s anything worse and he’s not stuck flat on his back. His obs are fine. Why didn’t the GP refer him directly to a physiotherapist?” The coordinator shrugs.
What he doesn’t say, but what we both know is that if the GP referred Ken directly, there would be a long delay before he would see anyone. This way costs more, involves more people and isn’t a proper use of an emergency service, but he’ll get seen quicker and that reduces the possibility of litigation.
* Names have been changed
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