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The uncoordinated NHS



Failures in the NHS aren’t unheard of, but how often does disorganisation get in the way of simple care

Greater thinkers than I have implied that the NHS is a lumbering, archaic, uncoordinated organisation. Yet I have vigorously defended its virtues and excused its shortcomings having given 40 years commitment to it. But recently I have lost belief and confidence.
What happened? My long-term friend, Grace, fell and required supine transportation to A&E with mega doses of morphine. Twelve hours later she was transferred to a spinal orthopaedic unit – and the nightmare began. From being an articulate, calm and capable systemic psychotherapist employed in the NHS she descended over five days into a weepy, depressed, frightened and complaining patient. On every level, she was worse than the day she was admitted and I was increasingly embarrassed and appalled at the process of her care. Her condition was not dramatic, life threatening or unusual. It was a basic clinical situation that happens to hundreds of patients: severe back pain post-trauma, needing assessment, diagnosis and treatment to discharge her home to recover. Seems simple enough?  
To brace or not to brace for fractured vertebrae: that became the question. But the shiny new registrar (one of all NHS doctors rotated on the first Wednesday every August) did not instil confidence, citing he was unaware of the consultant’s preferences and procedures in his new placement. Grace’s assessment required porter transportation for MRI scanning but the jarring bumpy journey on her bed actually increased her pain. Weekend cover delayed interpretation of her scan and that delayed the work of the physiotherapist to enable her to manage stairs, which was a condition of her discharge home. The physiotherapy programme depended on timely pain relief from nurses so Grace could learn to walk with confidence. Despite good ratios, the nursing care was haphazard (including morphine left at her bedside with no instructions or proof of ingestion) with no consistent, objective measurement and recording of pain levels – crucial to inform drug dosages, mobilisation and discharge planning.  
Each day further exposed gaps in the coordination of Grace’s care. Her anxiety grew as the excuses for poor communication and inefficiency became unreasonable. She wanted to be at home as much as they wanted her bed. She wanted a decent meal and a hot cup of tea. She felt like a nuisance. She was increasingly distressed by her uncontrolled pain compounded by lack of sleep from disturbances on the ward. Bizarrely she was deteriorating in a precious hospital bed! Stress was adversely affecting her judgement, pain levels and healing.
Grace’s journey and her observations as a systemic therapist and a patient illustrated the vital link between recovery and team coordination. She was hospitalised for eight days: it could have been four with better managed processes.   
Headlines about NHS failures are predictable, but I watched another form of failure – and it was not due to staff shortages, lack of funds, agency nurses or too many managers. It was due to a lack of systems and joined-up thinking on one ward in a major teaching hospital in England. Patients deserve better than this.