Let’s be honest – the past few months have been tough for anyone working at the hospital coalface. Even the most optimistic masters of NHS spin will have had difficulty denying some of the harsh realities which have faced staff, and patients; often on a daily basis. The Royal College of Physicians’ report Hospitals on the Edge, published last September, presented a gloomy picture of a system on the brink of collapse, becoming overwhelmed by year-round demands which continue to grow inexorably. Then came winter, Norovirus – and Robert Francis. His much anticipated, and long-delayed, report with its 293 recommendations, should be seen as a wake-up call to those in the position to effect change. The political, and media focus so far has been on the failures to recognise what went wrong – target culture, whistleblowing and regulation, as well as individual failings. All of these need to change, but the root causes of the problem should also not be forgotten. I have no doubt that many healthcare workers and patients reading the report from across the UK will have had days, and experiences which were not dissimilar to many of those described in Mid Staffs. The demands on our service, and the expectations of its users is rising; and yet we cannot expand our capacity to meet these demands. The past decade has seen countless efforts to improve efficiency and flow at the hospital front door: admission prevention schemes, ambulatory care, community geriatric services, chest pain pathways and rapid access clinics, to name but a few, have squeezed down the length of hospital stay for many patients. Undoubtedly there is more that can be done; systems can still be improved, but the hamster wheel needs to turn faster and faster each year – and the hamster is getting tired.
Underlying the daily battle to maintain flow through our emergency departments and acute medical units is the issue of capacity. The sight of an empty bed on our AMUs is a rarity on most mornings, despite good evidence that systems work better with lower occupancy. But it’s not just about hospital capacity – our entire health and social care system is bulging at the seams. We often blame ‘delayed discharges’ – patients whose medical treatment has been completed and whose care could be provided in a different setting – for all of our bed pressures. In reality this is just another symptom of the strain on our service. Integration of health and social care budgets is being explored in some areas and has real promise to reduce delays, but any savings need to be re-invested to maintain, or expand capacity. Of course the solutions are not straightforward – were that true we would have found them by now, but change is needed, and it needs to happen quickly if we are going to prevent a recurrence of the disasters of Mid Staffs.
Headache and hemiparesis is the theme of three of the case reports in this spring edition. James Schmidley and his team from Virginia highlights the importance of a careful history and examination before presuming that stroke is the cause of unilateral weakness in a patient with a normal cerebral CT. The consequences of administering thrombolysis to a patient with a spinal bleed would be disastrous; recognition of the importance of neck pain in one case and the identification of a Brown Sequard syndrome in the other ensured that the appropriate imaging was undertaken to enable a diagnosis. Nelatur and colleagues have included a useful table demonstrating the differential diagnoses which need to be considered when a patient with HIV presents with a neurological deficit. The targeted use of cerebral imaging and cerebrospinal fluid analysis will usually enable the cause to be identified so that prompt appropriate treatment can be initiated.
I make no excuse for including another article on sepsis – in fact this is the second in a series of 3 papers which will appear over the coming editions. By the time this edition is published the Health Ombudsman’s report on this subject is likely to have been released; Joel Meyer’s article on p5 provides further evidence of the scale of the problem which faces acute medical units and the importance of designing systems to provide rapid recognition and prompt treatment. Some of the solutions will be discussed in the next edition of this journal, and also in a symposium at the SAM meeting in Coventry: I hope many readers will be able to attend this meeting on the 9th May and look forward to meeting some of you there.