Monday, 28 November 2011

NatWest Bank Branch problem

I've just had 25 minutes of my life stolen from me by the NatWest Bank.

I used to have my main accounts and savings with them, but those were removed to another bank long ago following poor service and dubious interest rate practices. My wife and I have a joint account with the NatWest ever since we married over 30 years ago, but I cannot access it because the bank lost its record of my date of birth. However that's another story.

My company currently banks with the NatWest, but needless to say that customer relationship is hanging by a thread. It is only the work required to notify our clients and suppliers which protects the NatWest. We no longer leave any substantial sums of money in that bank. It goes elsewhere to where we know our custom is valued.

I've taken a day out from my business and was tidying some paperwork in my home office when I came across a bunch of shares dividend and royalty cheques I'd overlooked. Mostly I use direct payment of dividend/royalties into my other bank, but there are a few I still handle manually via the NatWest. I duly totted up the total value of the cheques and filled in the paying-in book prior to visiting the local NatWest Bank branch. As I'm in London at the moment it just happened to be the Lewisham branch. When I arrived at 2:25pm I found a long queue snaking around inside the branch. I checked my watch suspecting a long wait would follow. Only two counter positions were open.

I was not disappointed. It took 25 minutes for me to reach the front of the queue. During the wait I'd seen fourteen people turn away from the branch when they saw the length of the queue. By that time an additional counter position had opened. The manager tried to make the claim that refurbishment works would be completed within a couple of weeks and the queuing would not happen. What total nonsense! The queue was there because there were not enough counter positions open. In fact their refurbishment work is reducing the physical number of counter positions.

Perhaps the NatWest bank regards 25 minutes as an acceptable waiting time for their customers? I most certainly don't. The rot started when the retail banks decided it was a clever idea to remove Branch Managers. You know the type, they'd recognise you in the street and would have an idea of how much money you owe/deposit in the bank. When things went wrong with their service you'd know who to complain to. Instead now the NatWest wastes its money on television advertising spouting propaganda that the NatWest is a caring bank or something similar.

Saturday, 26 November 2011

Another senior nurse goes from UK NHS

Yesterday a highly skilled senior Cardiac nursing sister left the UK NHS. She'd worked at a central London hospital for many years. During the period she self-funded BSc and MA degree qualifications in medicine. She was managing a ward of critically ill cardiac patients. Tired of the clinical nurse staffing cuts under Lansley, the excessive unpaid overtime (12 hour days) and professional bullying abuse from some doctors/managers she decided to leave. She could no longer tolerate the disrespect from her Acute Hospital Trust employers.
She's looked around and has found a senior post in a middle east hospital. She's instantly doubled her salary, has paid for accommodation and it is all tax free.

It is fascinating yet unsurprising that the Acute Trust Board discuss a survey on staff concerns and conclude that people are happy. In reality the medical staff are angry and frustrated. It is time for the board members to get away from the board room and go actually meet the workers. Such bullying can have severe financial consequences.

Thursday, 24 November 2011

Death by attrition - Walk-In Centre

I'm watching the death by attrition of an NHS Walk-In Centre:-
  • Buildings closing (scheduled to be demolished quickly after);
  • Alternatively buildings given to a GP practice; even though they are a private concern;
  • Primary patients directed away without treatment ("Go to your GP or another clinic such as sexual health");
  • Any vacant position arbitrarily removed, regardless of the reason for the vacancy.
  • Senior nurses bullied and excluded from management meetings to encourage them to leave;
  • Senior nurses made redundant;
  • Junior nurses told their jobs are being regraded (downwards) with no real consultation;
  • Overnight working in A&E (not primary care) imposed regardless of contract;
  • Nurses diverted to streaming duties in A&E;
  • Nurses joining a union for the first time ever;
  • Specialist computer systems for patient consultation records abandoned and no further maintenance paid.
  • Services like Emergency Contraception cancelled - "go to another clinic" even though it is closed and the patient would need an appointment. 
  • Senior administrators making arbitrary clinical decisions
  • Budgets diverted away to other purposes.
All of this happens without consultation with the public and little warning to patients. All that is left is a deskilled shell nominally called a Walk-In Centre where a couple of nurses share a room somewhere in a larger department.  The PCT or Acute Trust claim the Walk-In centre hasn't "closed".

I've now seen this happen in four different locations over the past couple of years. It is a sickening waste of the public money invested in the creating WIC infrastructure and in the cost of building and training a skilled team of nurses. The public are left with no improvement of services as a result and the workload (queues) in the local A&E increase as a consequence.

One point never successfully handled under if retaining the patient records. They are supposed to be maintained safely and accessible for at least 25 years. This is an enormous cost risk, with the nurses dispersed there is no one able to dispute a legal medical claim. It is another consequence of the Lansley blind bull in a china shop leadership.

This happening in many places in the UK..

Edit: 17th April 2012

I recently had a chest infection which needed treatment with antibiotics to help it clear up. I've not troubled my GP for the past 15 years but I was not surprised to find I could not get an appointment until the following Monday (I was phoning on a Wednesday).  The receptionist's advice was to go to A&E dept or to the local Walk-In Centre. The local walk-in centre is one of those which has closed to be replaced by a ghost service located in another GP Surgery. I wasn't working so I drove to the WIC and was seen by a Nurse Practitioner within half an hour during the normal working day.  However I note that the opening hours have been cut down considerably and there is a map on the wall showing the "Catchment Area" street by street, within a radius of one mile. Proper Walk-In Centres do not have catchment areas! They deal with whoever comes through the door

The next closest Walk-in Centre by time of travel was open in December 2012, but it is now closed and the site is a car park.

Tuesday, 22 November 2011

More about NHS WICs

My blog piece on NHS Walk-In Centres has generated some interesting, if uninformed, comment so I’ll extend the article somewhat.
The idea of the Walk-In service is that patients can walk in from the street if they want medical advice, after treatment the patient walks out. The Walk-In Centre does not deal with A&E cases, though it is not unknown for ambulance crews to deliver patients to a Walk-In Centre where the condition is minor. The general rule is that if the patient has broken bones, needs a stretcher or has chest pains they get directed to A&E.
The WIC consultation is designed to be a one shot process. To assess and treat if appropriate; the WIC procedures are not designed for follow up sessions. If follow up is necessary the patient will be referred back to their own GP or to acute medical practitioners in an appropriate local hospital. The WIC may offer associated services such as a phlebotomy clinic (taking bloods), but not as part of their routine assessment process.
Mostly the cases for assessment and treatment are where the patient presents with headache, high temperature, colds and flu.  They are cases that would otherwise clog the waiting areas of the local GP or A&E Department. The WIC normally has a qualified medical prescriber present during their open hours, the usual route for patients to obtain medicines is to visit a local pharmacy, but the WIC will also hold a stock of common medicines for on-site dispensing.  When the WIC practitioner recognises a serious underlying condition the person will be referred back to their GP or in urgent cases on to the local A&E department. These referrals routinely represent a very small proportion of the cases handled.
The Walk-In Centre is normally led by a senior primary care nurse practitioner (Matron).  The lead nurse will usually manage both nurses and administration staff. Where appropriate the lead nurse /Matron will also employ a part time salaried GP to handle cases that need the skills of a GP but patient cannot for some reason attend their own GP. Most primary care nurse practitioners (PCNP) are qualified to MA degree level in an appropriate medical discipline with additional training specifically to work as a Nurse Practitioner. They will usually have at least 10 years experience of actual practice in the primary care area. They are decidedly not “Practice Nurses.”
The nurses in the walk-in centre are trained in medical assessment. They are expected to take comprehensive notes recording how they reached a diagnosis in each case. Those records are personally signed as a legal record by the nurse. The WIC matron regularly audits the patient records for quality for the nurses and the salaried GPs. Nurses are provided with detailed written rules as to how to perform their work. They are not permitted to perform such work unsupervised until they’ve been given a written sign off of their competency. They are also encouraged to routinely consult with their seniors when they have any uncertainty. A recent study in the litigious USA showed that less than 2% of Nurse Practitioners were mentioned in medical claims. In the UK the training and supervision is more intensive.
The concept of the UK NHS Walk-In Centre was created in the late 1990s by the Labour Government. It was a time when the public in some locations found it notoriously difficult to obtain a consultation at their GP’s surgery. GP surgery hours were limited and normal working people would have to take time off work for a 3 minute consultation with their local doctor when they finally achieved the minor miracle of getting through to the GP receptionist phone. Most GPs are not directly employed by the NHS, they act as sole practitioners or partnerships that have few actual constraints on how they deal with patients or which actual hours they are available to patients. GPs will contract with a local primary care trust to provide services, but it remains the fact that GPs are their own bosses.  The design of the Walk-In Centre service was to counteract that lack of service. WICs were specified to be open daily (364 days a year) from 0700 through to 2200 and thus not just constrained to working hours.
In the past few years WICs close to acute hospitals have been performing an additional function in reducing the waiting queues at the A&E departments. A skilled nurse(s) from the WIC would be stationed in the local A&E department adjacent to the waiting area to perform first line triage of attending patients. Those with minor conditions are advised (not mandatory) to visit the near-by Walk-In Centre to receive quicker appropriate treatment

Friday, 18 November 2011

The death of the NHS Walk-In Centre

One of the better changes introduced to the UK National Health Service (NHS) was the concept of Primary Care Walk-In Centres. They were located primarily in urban or city locations and were available to the public from 7am to 10pm for 364 days a year. In other words they were available at a time convenient to the public rather than a time convenient to local General Practitioners (GP).
The Walk-In centres were staffed by teams of highly skilled primary care nurses and led by autonomous Primary Care Nurse practitioners. The procedures and skills of the nurses, who were qualified to prescribe a full range of drugs and medicines, mean that they could deal with 98% of the cases without the need for a medical GP. For those few where the nurses could not handle a GP would be be employed on a part time basis by the lead Nurse Practitioner.
No appointment was necessary, people could literally walk in off the street and receive a medical consultation. Those with long term medical conditions would be given any necessary urgent treatment and referred back to their GPs for long term primary care.
The concept was extremely successful:
  • The costs were low. A WIC patient consulation was about £25 cost to the NHS. If that patient had gone a GP it would have cost at least the NHS at least £35. If the patient couldn't get to see a GP and decided to go to the local Accident and Emergency the minimum cost to the NHS would be £105.
  • Waiting times were good. Patients were seen within an average of 20 minutes or less in a fully staffed WIC.
  • The GP practices in the UK are run by independent contractors. They could turn patients away or close for the day at the whim of the GP Partners. The WIC teams were obliged to stay open, requiring permission from the local Primary Care Trust (PCT) and the Dept of Health before they could close.
  • The WICs helped to reduce queues in the local Accident and Emergency departments when patients with minor ailments were "streamed" away from the Hospital to the Walk-In Centre.
  • The WICs had a very low medical error/claim rate.
Sadly now most of the Primary Care Walk-In Centres have now been closed and their skilled teams of nurses dispersed. There are other reports on the Internet. In some cases the closures are hidden by the retention of a couple of junior staff and assigning them to a local GP or an A&E department. With the GP led Walk-In Centres you will see the daily open hours change from 0700-2200 to something like 0800-1900. In some cases the nurses are transferred to Acute Trust (Hospital) where the nurses role is subtly changed from being trained autonomous medical practitioners who diagnose and prescribe. Now they have to double check any decision with expensive doctors.

Originally the funding of the WIC team came centrally from the Dept of Health, it was ringfenced and could not be diverted to other purposes. Subsequently the ringfenced funding was merged into the general funding of the Primary Care Trusts. Opponents of WICs soon diverted the funding away from the WICs and the closures started. Remember the WICs often dealt with the failures of the GPs. They were seen as a threat to their profits. When the Conservative/Liberal coalition government came to power the scourge of the NHS in the shape of Andrew Lansley was released. He decided to wipe out the Primary Care Trusts and to hand the financial reins to the local GPs.  GPs see WICs as financial competition. It signalled the end of the PCT funded Walk-In Centres. Some have been absorbed by the budget hungry Acute Trusts (hospitals) to act as a streaming front end to A&E purely intended to prevent breaches of the waiting time targets. The Acute Trust, typically struggling under the financial burden of a PFI project, gains the funding from the Walk-In Centre, but the public lose the benefits.

These facilities are closed without public consultation, possibly leaving a ghost service to protect against public follow-up. The health administrators hate having their closure plans examined in public. Hundred's of thousands of pounds will have been spent in creating each of these Centres. It is often wasted. In one case the building was handed over to a local GP (private) in another the buildings will be demolished to provide parking spaces.

The consequence of these widespread WIC closures in London will be felt with greater queues in A&E, particularly at the time of the Olypmics 2012. Some of these walk-in centres were due to provide support to visitors. Here's a BBC report of a typical example in Surrey. They used to have a local WIC but it closed. You'll see a similar pattern in Croydon, New Cross, Whitechapel (E1), Homerton, Canary Wharf, Liverpool Street, Victoria and many other locations such as Stapleford, Ashfield, Leeds, Derby, Bradford, Salford, Harrow, Nottingham, Kirby, Trafford, Bromley, Manchester, Southampton , Barnsley, Warrington York Haverhill (Suffolk) Loughborough

An attempt to close Peterborough WIC.

Update: Late Nov 2011  One of the Walk-In Centres scheduled for closure soon,  as usual had a busy day as people attended for treatment yesterday. Many of those people would have gone to the local A&E Dept. Needless to say, the nearby A&E Dept managers are wetting themselves at the prospect of a 40% uplift in visits when the Walk In Centre closes. The A&E waiting time targets are going to be shattered, they already fail to meet waiting targets frequently enough as it is on present levels of patients.

Update Feb 2013: To make matters worse the local A&E Departments, which were protected by the Walk-In-Centres taking part of the load, are getting closed down as part of the service cuts. The (private) GP led Walk-in-centres open just 13 hours a day 8 - 7pm compared with Nurse led (NHS) 16 hours and the GP WICs have significantly reduced staff levels.