A Tale of Life, Death and Healthcare in the Information Age
Another normal day at the Princess Diana Ambulatory Care Centre (Truro). Trish Henderson signed in a few minutes early, to give herself time for a cup of tea and a quick chat with the other girls, as the schedulers were still known by surgeons half their age.
Many of her colleagues objected to the title. Trish didn't. She knew who was really running the show. Consultants could still have their airs and graces and little perks, such as separate coffee lounges, but in the National Hospital Service of 2010 managers called the shots: surgeons could be as patronising as they liked, but in the end were at the beck and call of schedulers and accountants.
Like many other such centres in Britain, PDACCT was founded at the turn of the millenium to cope with the crisis in handling routine operations or "elective surgery" in the pre-reforms National Health Service.
Most large towns had their "Princess Di Centre", which in many cases replaced the old district general hospital.
Under the old NHS system, surgeons handled a mixture of emergency and elective cases, from the same surgical wards. Patients needing quite minor operations were put to bed at the beginning of the day and left to wait until a theatre was free. After the operation, they were usually kept in at least overnight, to await the surgeon's ward rounds the following day.
The whole precarious process was prone to interruption from emergencies, especially in winter. Operations were sometimes cancelled after the patient had been anaesthetised. Despite regular political initiatives, waiting-lists lengthened inexorably.
From the 1980s onwards, the spread of day-surgery offered a way out. It was the product of new technologies and a desperate drive to cut costs. The term minimally invasive therapy, or "keyhole surgery", covered a battery of innovations. The most important were the quick-acting anaesthetic propofol and the laparoscope.
When the new tools first became available, some surgeons went overboard, trying them on all manner of conditions (those were the days before measures of surgical outcomes were published on the Web). Twenty years on, a better understanding of what was possible or worthwhile had emerged.
Trish approved. The revolution in imaging technology had certainly ended one source of waste, that of "open and shut cases" when people suffering from cancer were anaesthetised, opened up for surgery only for surgeons to discover that the tumour was too advanced for anything to be done and stitched up again.
Day surgery, made possible by "keyhole" techniques and advances in ways of viewing inside the body, made it possible to cut the cost and trauma involved in many routine operations. The full benefits, however, did not appear until the whole process of healthcare was built around the new technologies.
And that meant taking many decisions out of the hands of surgeons and giving them to managers, backed up with information technology.
Trish took her seat at the computer terminal, swiped her NHS smartcard through the reader and typed in the day's password to activate it. The scheduling system had already planned the day's routine, with the most serious general-anaesthetic operations in the morning, winding down to minor examinations, where the patient would be most unlikely to need recuperation time, in the evening.
To say that surgeons had been suspicious of such production-line mentalities would be an understatement. But by the late 1990s, compelling evidence had built up to show what worked and what didn't. Dabbling, by and large, didn't: there was a 100 per cent variation in operative deaths in units where procedures were not frequently carried out, compared with high-turnover centres. (There was even a buzzword for this revolution: evidence-based medicine. The fact that basing procedures on evidence was taken to be a breakthrough showed how desperate the position had become.)
Truro was a high-turnover centre. The capital cost was found by selling off surplus NHS land and the county's share of the national tobacco settlement. Running income came from contracts with the local health authority.
The centre also carried out procedures for private insurers. Private patients side-stepped the primary referrals process, so received their appointments more quickly, were personally escorted through the process and could check into a luxurious "step-down" hotel to recuperate. The medical procedures themselves were identical, something that insurance companies belatedly recognised when all but the most esoteric and exclusive private clinics slid into bankruptcy.
Unlike some other centres, Truro did not handle accident and emergency cases because of its scattered population, Cornwall had a dedicated A&E unit at the high-dependency hospital.
Despite the progress of artificial intelligence over the past 10 years, managing the flow of patients still needed a human touch. This was Trish's speciality.
Trish and the other scheduling officers had to be skilled at clinical terminology, basic patient needs and when to order extra care. Trish had originally trained as a clinical coder, before that work was made redundant by integrated hospital-wide computer systems. But like many senior NHS staff, Trish had accumulated a common-sense knowledge which turned out to be vital in running the new ambulatory care centres smoothly.
And in dealing with awkward customers.
At eight in the morning, the open-plan reception area was already full of patients and their relatives. Although every patient received a card with the exact time of their appointment and a phone call the day before to check that they were still coming some old habits died hard. People still expected to wait to be seen by the doctor.
One such hopeful shuffled his way to the reception/scheduling desk, brandishing a dog-eared NHS card, a paper card, for God's sake. Trish had seen him before, but the centre's procedures for treating awkward customers had to be followed.
Can I help you sir?
Not unless you're a nurse and I know you're not. It's me prostate, again, hurting like hell, kept me up all night. You've got to give me something for it. Just let me see one of the doctors for a minute, eh? I won't make any trouble, honest.
Trish sighed. Any big new walk-in facility exerted a magnetic attraction on patients who should be seeking attention elsewhere. Some, quite literally, expected miracles.
It's Mr Trevelyan, isn't it? Now, you know you can't go in without an appointment. Give me your card and I'll see what I can do.
She typed in the patient's national number, and consulted the Level One administrative record which appeared on the screen. The details appeared on a blue background, signalling a "heartsink" patient, usually someone who had been spending too much time in front of the Webtelly. It was a relatively common alert; much more so than the mauve which indicated serious mental disorder, or the red which would have caused Trish to press the security button near her left foot. Always better safe than sorry.
Now, let me see. Oh, dear, dear, dear. Your health counsellor is Dr Jablonski at Penryn, but there's no referral from her. Why don't you call in and see her? She can fix you up with everything you need, and if there's any cause for concern arrange a teleconsultation. Wouldn't that be a good idea?
Don't see why I can't see the doctor here. Them counsellors are no good. Never give you real medicines and that Dr Jablonsky, I've got nothing against her, mind, but she don't really understand, if you know what I mean?
No I don't know what you mean. She's one of the best-qualified counsellors in the district and I can see from your record that she's always making housecalls for your benefit. Shall I fix up another appointment through the system?
In theory, the National Hospital Service was supposed to be "customer-led". In practice, Trish thought, most customers needed a lot of leading.
She called up the Public Health Service network and opened up the Penryn appointments book. It was full (whose wasn't, nowadays?) but she entered a request, adding a brief note that Mr Trevelyan seemed unhappy with his medication and might benefit from a visit from the voluntary sector. Dr Jablonsky would read between the lines. With the familiarity of long practice, she hit the "send" and "print patient advice" buttons in quick succession.
Now, here's what I've done, even though I'm not supposed to. I've told Dr Jablonsky that you're still in pain, and to arrange to see you in the next couple of days. Now, as you don't have a Tophealth link I want you to phone this number tomorrow morning to find out when you'll be seen.
- In the meantime, keep taking your painkillers. If you really can't cope, you can ask for Urgicare, but don't waste their time. All right?
He shuffled off towards the exit.
The door to the surgeon's club room swung open and Sebastian Conroy emerged, adjusting his surgeon's greens pointedly. Mr Conroy was always complaining of the lack of anywhere private for consultants to change.
But he was a nice man, one of the few old-style senior consultants who had readily adapted to the production-line mentality of ambulatory care. Mr Conroy's red face, product of a summer largely spent in his yacht (what's the point of living in Cornwall if you don't go sailing, he always said) beamed.
Morning, girls. Let me guess: the computer's been impounded by the data protection squad, so I can spend the day pottering around Helford River?
It was a reference to an incident in Exeter, some months previously. Investigators had frozen an entire care-centre's information systems for an emergency information audit which in the end revealed nothing amiss. With no means of ordering tests or pharmaceuticals, let alone recording results, the centre had lost an entire day's work.
Sorry, Mr Conroy, you know we like to keep you busy.
Trish handed the surgeon a paper print-out of the morning's list, a favour he appreciated which was not extended to his more junior colleagues. He cast his eye down the long list of identical knee operations.
Hey ho, variety's the spice of life eh?
The phone rang on Trish's desk.
Princess Di, Truro
Mum, is that you? It's Bonnie.
Well this IS a surprise on a working day. Everything all right, dear?
Actually, Mum, it isn't. I've had some bad news about Dad...