Right Care, Right Place, Right Time

I attended a HSJ ( Health Service Journal) seminar on 26th January 2010. It was actually about using or selling a data tool called Interqual (registered trademark) and it was clearly aimed at A&E and acute illness scenarios (heart illness etc). However, applied to maternity services and birth its principles, I think, could be an eye-opener. If it was seriously and rigorously applied to maternity services and birth services I wonder if they would be structured very differently? AS Gary Lane said at the end of his presentation – short term pain for long term gain – restructuring services to give appropriate levels of care at the appropriate time will have long term benefits for patients and Trusts.

The seminar began with a quick overview of the financial situation of the NHS:

• NHS nationally has a shortfall of £20billion. This amounts to a big cash crisis.

• Trusts and PCTs have been informed that they will only receive 30% of 2002 levels ( this needs to be checked as was not on the slide) of the money they received for Acute admissions.

• Just 10% of PCTs have managed to reduce A &E admissions accordingly

• There is a continuing demand for quality assurance through QIPP (Quality, Innovation, Productivity and Prevention) and CQUINN

The Solution

Reduce acute level of care (ie in hospital, in patient care) and providing as much care as possible in patient’s locality and community.

My comment: Surely this is the nub of the issue with regard to how maternity care is structured? The complaint of many women is that their care is inappropriately centralised and clinicalised, and not there at the right time, place and level that they really need. From maternity services point of view women are going into hospital for birth inappropriately – the system is set up for care only to be in this location. So, for example, women turn up to hospital and complain that they keep being returned home in early labour – why not assess women at home and keep them there until they wish to go in or give birth? Homebirth services are provided as optional extras by maternity services rather than being structured into the care pattern for all women as, for instance above. For many women this would be appropriate localised care at an appropriate level, and would reduce acute admissions to hospital – unnecessary acute admissions to hospital.

Postnatally, regular midwifery and social care visits to establish breastfeeding and general wellbeing of Mum and baby dyad in first 2 – 4 weeks post partum could reduce acute admissions (eg for gastroenteritis of baby) and post natal depression. The question being does saving in one departments budget offset the extra spend in another? Ie If investment in low level social care (to establish breastfeeding for instance) has big payoffs in the acute budget ( readmission of babies for instance for preventable illness) will this be acknowledged and supported within the NHS structure?

A case example given was Rotherham – this was not maternity services but hospital acute care generally – however, if read applying to maternity services it is thought provoking.

The key issue to be tackled in Rotherham: Patients in acute beds who do not need to be.

The tool was the Interqual tool.

The objectives:

• Right care, right place, right time

• Admission avoidance ( patients being admitted into hospital that do not need to be)

• Developing Alternative Levels of Care

• Better care with better value (for money)

• Building locally based care

(Taken from the HSJ Rotherham Case study PDF http://mediazone.brighttalk.com/comm/Emap/12ce4a01b3-16351-3188-12894#  )

• Rotherham Partnership began implementing InterQual in February 2009 initially on three wards covering emergency admissions; trauma and orthopaedics; and healthcare for older people. It was also implemented in the community in a purpose built facility for people with chronic obstructive pulmonary disease.

• Case Managers assessed patients both on admission and throughout their hospital stay and where they identified that patients could be cared for more appropriately elsewhere, they worked to facilitate a supported discharge.

• All patients are reviewed against InterQual’s admission criteria and then against the continued stay criteria while they are on a ward using the system. In the first16 weeks (16 February 09 to 8 June 09), 3631 reviews were undertaken on 892 patients.

• .The hospital found that 49% of the admission reviews met the criteria for an acute admission; 45% did not.

• The continued stay [in hospital] reviews show that 15% met the acute criteria and 77% did not.

• This data shows that the 77% of continued stay reviews and the 45% of admission reviews which did not meet the criteria resulted in patients occupying an acute bed. This meant a total of 1574 days, when patients could have been cared for at a sub-acute level if that level of care had been available in Rotherham.

• InterQual has subsequently been rolled out in Rotherham across respiratory medicine, and plans are in place to use the criteria in a modified way on the Stroke Unit and obstetrics and gynaecology in order to undertake retrospective audits.
• Case Managers report numerous examples where experience told them that a patient needed moving to a less acute environment but InterQual provided the evidence-based assessment to confirm this.

Long term objectives (from HSJ seminar)

• Using Interqual data to identify the number and type of patients who are not meeting or requiring acute level of care to inform future commissioning.

• To commission the most appropriate service model location and resource structure to deliver this.

• Changing the culture of the organisation and clinical practices.

• Identifying bottlenecks (eg bed blocking or delivery room blocking)

• Ensuring medical intervention at appropriate times, levels, and places.

• Short term pain for long term – redesigning care system so that they are efficient in the long term so that care is provided when and where it needed says Gary Lane.

Right Care, Right Place, Right Time

For Mums that means: One mother one midwife, at home, for the birth

Harsh reality and gritten teeth

This week the snow finally cleared.  The ice on the windows became condensation.  I could get dressed without the heater being on for 40 minutes first!  The coldest winter for thirty years and we move into the coldest house in Bradford!

But snow gives a beautiful dressing to everything, ice stops people coming to see you; huddled around the fire you don’t venture into the rest of the house to see what needs doing.  This week the snow cleared and out of my office window I can now see the builders rubble, the plaster, the discarded cardboard boxes.  The over-grown lilac has lost its sparkling dressing and looks leggy and messy.  Without the Victorian Christmas look the porch looks less Dickens and more tatty tenement.  What will people think as they come to the door I fret? – They won’t want to come to a birth resource centre looking like this?

And though the hall has beautiful pannelling it needs touching up and a polish, and as fast as I clear it up another lot of stuff is dumped by the front door on its journey up, down, in or out of the house.  The living room needs half a dozen boxes removed and just needs tidying up – and one of those Belgium-sized sofas removed.  Could anyone come here and believe this was a place to learn about birth and be nurtured in it?

And the therapy room – the fridge as the family call it – because that is what it is.  A gaping doorway into a once lovely Edwardian glass and wood extension makes this the coldest room in the house.  And so it has become the repositiory of all boxes and items without a home and not essential for immediate use.  And it feels empty and sad and in need of a coat of paint.  Could this be a therapy room where women are nurtured and loved, and where healing is offered? Could you see it and believe it?

I believe it, I know it . . .but will others see it and believe it too?  People who I need to come to the groups, facilitate the groups, provide the therapies, provide the funding?  Can they see it?  Could they come to a place with a scruffy garden with daffodils peeping through as scouts for the beautiful garden we will make  – could you?  Could you come and sit and learn in a big room that is beautiful but not finished – like when you wear a suit and then sturdy boots for the weather? Or your pretty dress has the stripes of a sickly baby?  Could people feel  comfortable with cosy but not yet posh? Could you?

And could a therapist see a beautiful but cold drab room and believe that this in 4 weeks could look pretty good and feel wonderful and 12 months be perfect?  Could they?  Could you?

This week I have faltered because the snow has cleared and the harsh reality on a dull wet day is that there is alot to do.  The house IS tatty and you can’t replace all the windows of a Victorian Edifice for under £10 thousand pounds and we spent that on getting the roof weather proof and the cellar damp proof.  And my wild roses won’t flower until June and we won’t be cutting the trees until later in spring.

And my kind and honest friends – are they being really honest when they share my enthusiasm and say how lovely the house is and capture my vision and say everything will be OK? And that all it needs here is a coat of paint and there a sort out?

Sometimes realising a vision means holding on to your vision with gritten teeth, believing when the reality tells a different story, and just working task by task.  Sometimes only your friends can see the progress.  Sometimes you need a holiday.

I am a believer.

“If I count how many steps it would take to climb this mountain I would go no further: I would sit down and cry. But I have decided to be a believer.”

I have not blogged for a good while. And I am sorry for that but let me tell you something of why. We had this dream, this plan. It started off as a plan to put work and home together, to simplify our lives so we did not spend 2 hours and 20 miles a day in a car taking children to school and us to work. We wanted a more sustainable lifestyle. But then we looked around some houses homes, premises – all kinds of things, all over the north of England and Wales. Mind you, there seemed to be a theme, as our favourites tended to be old doctors surgeries.

And so another dream began to emerge. “What a lovely big room” we thought. “It could work for classes, courses, training etc. And look at this room! This would be so fab as a therapy room.” Basically, we realised that we might be able to have an office, a pool storage and a Birth Resource Centre. That phrase was given us by a doula moving down from Edinbugh who had worked with Nadine Edward’s set up. She gave me the concept I was looking for: A resource to parents, midwives practitioners for maternity birth and beyond. A place to be informed, nurtured and massaged as well. A network hub for birth.

That was the dream. Now the reality. A large family a small income, a small but expanding business, a credit crunch. After 18 months of arguing with banks (No, the Royal Bank of Scotland does not lend to small businesses any more) and vendors (What? You want to knock another £10 thousand off for the tree in the cellar?”), we finally purchased 89 Bradford Road, known to the children as 89 Zoo Lane ( Do you remember ’64 Zoo Lane’ on TV?) and to David as Gormanghast.

Our new home is a gargantuan Victorian edifice with no central heating system. After the TV programme ‘Victorian Farm’, we’re going for the spin off: ‘Victorian House’ complete with real TB. Spread over four floors there is ample opportunity to lose children, ladders, staircases and whole rooms. Visitors and workman have been known to appear in doorways looking puzzled and nonplussed asking “Where have the stairs gone?” “I thought they were around here somewhere”. And so our enchanted house casts its spell.

We got the keys to the focus of our dreams on 30th November. On 1st December the builders moved in to remove the tree from the basement wall, put the stairs back where they need to be for health and safety reasons as well as reaching the fourth floor, and to make other basic repairs – such as restoring the roof and chimney etc.

It was an exciting week when we moved in – and yes it took a week to move the Weston tribe with their goods and chattels plus expanding business into one set of premises – (and yes we do now have a tradesman’s entrance!). Unfortunately as we moved in, the central heating boiler moved out into the skip and we had the white Christmas we would never have contemplated otherwise. Ah the twists and turns of fate! Our children have now learnt that getting ready for bed means putting your pyjamas on top of your day clothes. And no one is allowed out with less than five layers of clothes. Tom says he prefers ‘windy Walney’ (our holiday home) with outside loo because it is warmer there. And it is.

The Scott of the Antarctic Memorial Society are holding their annual re-enactment at 89 Zoo Lane to which all who have the appropriate clothing are invited. Bring a penguin. Placement students from the British Antarctic Survey are also welcome. (None of this is true but its sounds good! – ed)

And so here I sit with large jumper retrieved from case of clothes from my student days and woolley hat (I may look silly but I feel warm!) writing my blog. IN four weeks time I want the embryo Birth Reosurce Centre to be ready for birth – I suspect, like every mother, I will have to learn the art of contented waiting. In the mean time there are boxes to empty, furniture to arrange, walls to paint, workmen to find and organise. And at the same time, meals to cook ( where is that pan it can’t be in a box), washing to do, children to take (or not) to school, customers to deal with, bills to pay.

If I count how many steps it would take to climb this mountain I would go no further: I would sit down and cry. But I have decided to be a believer. So instead I count the steps I have made and look back at how far I have travelled. With the courage this gives me I can turn my face forward.

I know that in three years time we will hardly believe the distance we have covered. I am a believer.