2018 has been a good year so far. In January, the PRSB held an excellent meeting at the RCP in London with the aim of defining/refining a dataset for referrals. Later in the year, National Services Scotland and ISD held a workshop in Glasgow where attendees were asked to take a fresh look at how we manage Outpatient activity. As you might expect, both meetings generated some common themes. At the top of my list is the concept of a "Named Consultant" - something that was referenced explicitly in the Francis Report. Published just over 5 years ago, one of the key recommendations of the report is that "every patient admitted to hospital in England has a named, identifiable clinician assigned to them. These are known as a responsible consultant or clinician". I applaud the use of the more generic "named clinician" (as opposed to "Named Consultant") as we know that good quality care can be delivered by any career-grade doctor, but I wonder how achievable the "named clinician" recommendation is in 2018.

The GMC and the Academy of Medical Royal Colleges have both thrown their weight behind this concept in the belief that it can improve care and enhance safety. There may well be benefits to patients in knowing that Dr X or Mr Y is looking out for them and ultimately carries the can for any adverse incidents that may arise during an episode of care, but the reality of working in the hard-pressed NHS raises some concerns about how practical the arrangement is. 

To give an example, let's assume that Mrs A becomes unwell on a Saturday morning with a condition that she has had before, and for which she has received treatment at the local hospital under the care of surgeon Mr P. Her post-operative care was good but she developed a complication and spent some time in Critical Care. Thankfully she recovered fully and ultimately went home and back to independent living.

This time around, she is acutely unwell, on a background of previous surgery and requires immediate care. She phones NHS 111 and they send an ambulance that takes her to A&E. She is seen quickly by the A&E consultant Dr Q who sends some bloods and orders some imaging. Dr Q's name is on the order requests (which are electronic, of course!).  At this point, Dr Q is Mrs A's 'named clinician' - the first clinician to assess her and initiate treatment in this care episode.

Dr Q decides that Mrs A has an acute abdomen and requests help from the on-call surgical team. Ms S, the consultant surgeon arrives. She agrees that Mrs A has serious, life-threatening intra-abdominal pathology and arranges for her to go to theatre (OR) directly from A&E, as she is critically ill. Dr Q now hands over care to Ms S and Mrs A is transferred to the Operating Theatre (OR) where she is met by Dr T, the consultant anaesthetist on-call.

Mrs A's op goes well but she is too unstable to go back to the ward and is instead transferred to Critical Care where she is looked after by Dr W and his team. At this point in her episode, Mrs A has been cared for by Dr Q (A&E), Ms S (Surgery), Dr T (anaesthetics) and Dr W (Critical Care), plus numerous other members of the A&E, Surgical, Anaesthetic and Critical Care teams. A legitimate question at this point is "Who is Mrs A's Named Clinician ?". Likely candidates are Ms S or Dr W but don't forget that Dr Q (A&E) is probably the first name on the request form in the Order Comms system and may be hearing more about Mrs A than is strictly necessary.

Let's say that Mrs A does well and is discharged to Surgical High Dependency the following day. Sadly, on her third post-op day, she gets some chest pain and has evidence of an MI. She suffers a cardiac arrest but is resuscitated promptly and regains consciousness. She continues to have arrhthymias and her surgical team call in the medics. She is transferred to CCU (Coronary Care Unit) under the care of Dr X and is stabilised with appropriate anti-arrhythmic drug therapy.

The rest of her care is uneventful and she survives to discharge home without any significant morbidity. Before she leaves the hospital, she has a CT angio, performed by the Consultant Radiologist Dr Y.

In this episode of care, Mrs A has been looked after by six consultants, a squad of doctors in training, possibly some SAS docs, nurses, physios, OTs and students of varying ages and abilities. It is likely that the "Named Clinician" for this episode of care will be recorded as Ms S (the Surgeon) as the admitting specialty. Some questions :

  • Is Ms S a valid assignment as "Named Clinician" ?
  • What happens if Ms S goes on leave (of any type) the day after Mrs A's operation - does "Named Clinician" pass to the on-call surgical team (who change regularly) or is there a process for handover of care ?
  • How does the Order Comms system track "Named Clinician" and ensure that result reconciliation/workflow follows the patient and not the staff member ?

In considering the answers, it's fun to imagine how the care pathway and workflow would change if we discarded the concept of "Named Clinician". Instead, Mrs A sits at the centre of a "care circle", surrounded by care-givers of different grades and specialties. Each time there is an intervention, the name and grade of the person making the intervention is recorded. For joined-up care, this person must be a member of a team and the result of the intervention has to be reconciled or actioned by one of the team members. The questions then become :

  • How do we build clinical systems that support a model of care that puts the patient in the middle, rather tying each intervention to a "named clinician" who may or may not be able to participate in further care ?
  • How do we define and capture clinical roles so that staff can be represented as "organisational units" in a way that allows for : shift working, multi-disciplinary care, short-notice leave, and transition through different specialties ?
  • How do we ensure that results of interventions are available immediately to the appropriate care-givers for reconciliation and made available more widely for anyone with a legitimate care relationship ?

Finally, can we come up with a framework that represents all these process rules and decision-making in a format that is easy to understand, easy to follow and easily transferable from one care setting to another ?

Hopefully some food for thought...