This guide, written by a senior doctor, provides insights into the hows, whys and whats of being a patient in today's NHS:
How to treat the Health Service:
A Patient's Guide to using the NHS
There are two very important things that patients always seem to forget when thinking about the NHS:
First – illness is frequently horrible, painful, undignified and not uncommonly results in death. It will be the worst thing that has happened to you, irrespective of the standard of medical care.
Second – the NHS is a state run organization. While it is not exactly similar to the old state run British Railways or British Telecom, they do share some common ground. Because it is an enormous taxpayer funded institution, it is kinder to compare it with the immigration queue at the airport, the HMRC or the Benefits System than the standards set by your favourite hotel.
A visit to outpatients:
If your GP has arranged for you to visit the hospital clinic, you are well on your way to getting a specialist opinion and are now in the Hospital System with access to its doctors, diagnostic facilities and more.
Your clinic appointment letter:
The NHS has not mastered the simple art of letter writing. It may take you some time to realise what the clinic appointment letter is for. Granted, somewhere in the text there will be a time, a date, a place and the name of the clinic. Much more prominence will be given to a number of grandiose corporate announcements including the hospital's non-smoking policy, threats about illegal parking and statements about the Hospital's record as an equal opportunity employer along with a number of NHS catchphrases and mission statements. You will be warned not to come to the hospital if you are feeling ill and might have an infection. There may be some health and safety advice about slippery floors in wet weather and the need to familiarize yourself with fire exits. It will very likely finish with 'yours sincerely' followed by a blank space under which is written the name of a department such as 'Planned Care' or 'Outpatient Services'. It will have a telephone number to ring if you wish to change your appointment. This is usually engaged, unmanned or connected to an answer machine.
Clinics are called 'outpatients' in hospital parlance and they have a number of characteristics.
First, they hardly ever run to time. You will be given an appointment slot, but it is most unlikely that you will be called in at this exact time and 25 minutes latitude either way is considered fair. Both doctors and patients are unlikely to keep to their allocated time, there are interruptions and hold ups which make it invariably the case that timings go out of the window. It is usual for most patients to be allocated 15 or 20 minutes if it is your first time and 5-10 minutes if it is a second or follow up appointment. However, this timing includes the time it takes to get all your test results up on the computer screen (sometime a good five minutes), the doctor to dictate a letter (only a couple of minutes), any necessary form filling (sometimes over five minutes) and the walk (or ride) from the waiting area to the consultation room (sometimes seems like 10 minutes). So there is not always that much time left for the business of the consultation itself.
The saviour of the clinic is the DNA (did not attend patient) – sometimes about one in five of the people booked in do not turn up. These are despised by NHS managers as timewasters and parasites (the hospital does not get paid and the managers picture the doctors as sitting idle when the patients do not arrive). But for the clinic they allow time to be made up and have often saved the patients who have arrived from a lengthy wait. On the few occasions when everyone does turn up, it usually means a very long and slow morning / afternoon for both doctors and patients.
Patients sometimes get very wound up if they think somebody else is pushing in in front of them. It is true that the nurses and other staff running the clinic have it in their power to switch the running order and frequently do: from the doctors' point of view this is of little importance and interest as long as a patient comes through the door when called. Why might they risk the fury of waiting patients by altering the timings? Sometimes it is obvious, for example the patient with learning needs who is shouting or screaming in the waiting room will often be ushered in as soon as possible to get them out of the way. Another reason is when the old and frail arrive by hospital transport and there is an ambulance waiting outside to take them home afterwards (already loaded up with other patients). It is sadly sometimes the case that if an unpleasant or intimidating patient starts to complain then they will also be put to the front so everyone can have a quiet life. Sometimes the nurses will change the order simply because someone has arrived early, has been waiting a long time and the staff feel sorry for them.
Second, you may think that a 15 minute appointment will require in total something in the region of 25 minutes of your time, allowing for finding the right place, checking in etc etc. Think again! Allow half an hour for parking and quite a bit if time for locating the clinic itself if you are unfamiliar with the hospital. You will almost certainly then have to present yourself at a reception desk (possible queue) to announce your arrival (10 minutes). It is quite likely the nurse will want to take your blood pressure / weight / urine test before you go in (15 minutes). The consultation itself may overrun, particularly if there are medical students or unexpected developments. After the consultation you may well have to book another appointment (join a queue for 10 minutes), go for a blood test (a possible 45 minute wait) and find another department in the hospital to book a test, for example an X ray. Then you will have to familiarize yourself with the highly complex parking payment arrangements before you leave (this may require a trip to the shop to get the right amount of loose change). This is why a simple trip to pop in and 'get a test result' can easily last three hours.
The Hospital appointment letter usually says that when you visit the clinic it cannot promise you will be seeing any one doctor in particular. This is confusing as, although many clinic are given a general title such as 'Osteoporosis Clinic' just as many are called after the Consultant in charge, even if he is not actually there. He may have retired and be replaced by a locum, he may be away or he may have delegated a part of the clinic and turn up a bit later. So it is usually a mistake to request, as many patients do, to 'see the consultant'. This tends to mark them out as difficult to please, dissatisfied with their last appointment, or tending to self-importance either from the perception they have an engagingly difficult problem to sort out or have struck up a unique rapport with the consultant. Not only may this incur an additional delay but the non-consultant you see may suit you even better than the consultant.
After the clinic appointment the doctor who sees you will dictate a letter to your GP and almost always a copy of this letter is posted off to yourself. This not only gives you the name of the person you saw – which by now you will have forgotten – but also his/her qualifications, and what is going to be done next. This letter is written in the full knowledge that the patient will spend more time reading it than the GP so it is well worth looking at it and seeing what is being said. Don't throw it away and bring it to your next appointment or visit in case your notes have been lost or the computer is having a day off.
Dos and Don'ts of Outpatient visits
Do take a book or something to help pass the time – clinics tend not to have piles of magazines as they are an 'infection risk"
Do factor in the possibility you could be at the clinic far longer than you anticipated ...
Do save your symptoms for the doctor as the nursing support staff are usually there to help with specific tasks and might not actually communicate much to the doctor during the running of the clinic
Don't be worried if you are late – they will almost certainly still see you and are used to people tuning up in the wrong order.
Don't carry heavy shopping / multiple bags as there is often a fair amount of getting up / sitting down / walking to and fro during a visit.
Don't feel shortchanged it you don’t see the Consultant or Professor personally.
Who is your doctor?
Any patient who is seen in the hospital clinic or who is admitted (that is gets beyond the A and E Department) comes under the umbrella of a named consultant. Even if you are directed to the a department such as 'Upper GI Surgery' or 'Ophthalmology Outpatients', it is still the case that in the hospital administration system you will be allocated to a particular individual senior doctor. There may seem to be little point to this, as it is quite possible you will never actually meet your Consultant and even find out his or her name. However, should there be a complaint, a mishap or if something such as a case of MRSA crops up, then it is this unfortunate Consultant who will be asked to give an explanation, make amends and generally accept responsibility. It is also something of a strength to the patient to know that there is a particular individual acting as a long stop and who has something of a (sometimes vicarious) interest in your progress.
Despite the continuing role of the Consultant in the NHS, there is a trend to pretend that the patient is the property of a department or a section of the hospital management structure. Your letters documents from the hospital may well be from someone or something in 'Acute and Emergency Services', 'Planned Care' or 'Critical Care' to give a few examples. For the patient (and even for many of us doctors), these management divisions are meaningless, and often change every few years as the management structures are dismantled and reassembled. No, it is the name of your consultant who is your all important link with the hospital.
When you actually end up with the doctor, it is very likely she will introduce herself and that you will immediately forget her name and title. It will also be tucked away on the identity badge but this may also be difficult to see – added to which there is a trend to minimize the title to 'doctor' rather than provide any more details of your rank and responsibilities.
There are many advantages in knowing exactly who is your consultant. Any details about waiting lists, results and documents can be routed through her secretary or office. If you are a regular attender, it gives you some hope that you will be able to establish some sort of personal relationship with the hospital. Any requirement for insurance claims, occupational health reports and the like will have to go through the Consultant. Your Consultant should as well be prepared to act as your advocate and ally if the hospital as a whole is dragging its feet with any aspect of your treatment.
In short, no matter how faceless the Hospital system seems to be, you will be designated a particular consultant and familiarisation with her name and secretary will help open the door to better communication and treatment within the health service.
Who is your doctor? – Dos and Don'ts
Do find out the name of your consultant and your hospital number – very useful for queries and requests etc
Do keep copies of the clinic and hospital letters of which you will be provided copies – both as a source of information to yourself and to remind the doctor at your next appointment in case of a computer glitch or clerical breakdown.
Don't be concerned about the name and rank of the individual you see in a clinic
Don't be tempted to judge the seniority and expertise of the doctor by his / her age, clothing nationality etc, Currently, all NHS doctors have to abide by the Department of Health's 'dress code' This has been dreamed up with the laudable but totally unproven intention of making it more difficult to pass on infection from doctor to patient via infected neckties, cuffs and other attire such as pendants and wristwatches. Whereas there seems to be no evidence infections rates are down, the policy has without doubt made doctors look at best 'smart casual' and the traditional era of the younger doctor in a white coat and the consultant in a suit is over. There is in truth no way of learning anything about hospital staff from their dress: most nurses wear a form of trouser suit and are indistinguishable from the cleaners. Anyone with a walkie-talkie is likely to be a porter or security man. Most staff who deal directly with patients will speak English. And as a rule of thumb, the fewer tattoos you can see on an individual, the more senior they are.
Why have I not seen my consultant?
Despite the NHS having an army of highly trained Consultants, and claiming that it is 'a Consultant Led Service', it is quite possible you will never actually meet your Consultant. Indeed, one of the biggest frustrations of modern day healthcare is the lack of any continuity in which doctor you see, whether it applied to the GP visit ('you just go in and see whoever happens to be available') or elsewhere. This problem is even more noticeable when you are in the hospital itself and is one reason why many patients lose track of who their doctor is, why they are there and almost everything except a vague idea of which department they are heading off to.
The reason for the problem is largely due to the size of the teams of doctors working in any department and the transitory nature of the posts held by the doctors who are not yet of Consultant seniority. It is only the Consultant who has a permanent position at the hospital, all the other doctors are described as 'training grade doctors' and almost all of them have a contract which means they have to participating in a complicated timetable of moves from department to department, and hospital to hospital over a period of years. The result of this is most of the hospital doctors under the age of about 35 will be temporary members of the department, destined to see patients under a given consultant for 6 months or less, before moving on (or 'rotating') and quite possibly never finding out the longer term consequences of advice and treatment provided to his / her patients.
The lack of continuity can reach Kafkaesque levels once you are admitted to a hospital bed. At this point it becomes very likely you will not see the same doctors twice, unless you are unfortunate enough to become stuck for a period of days or weeks with a longer term problem. Much of the reason for this is down to the shifts and rotas currently in force to provide 'cover' for each department. The old system of teams has long ago broken down, destroyed by the European Working Time Directive and other initiatives to consign to history the old fashioned and inhuman hours which used to be worked by doctors in the last century. The doctor called to see you will be the one on the rota for that shift. The advantage of the shift system is that the doctor will have been on duty for a maximum of 13 hours and will not be befuddled by fatigue. The other side of the coin is that he will quite probably be starting from scratch with your problem. He will also be unlikely to be dealing with the longer term issues and will take a short term view of whatever has to be done.
You might well wonder how the transient pattern of work of the non-consultant doctor is organised and why. These are the 'junior doctors’ or 'training grade doctors’ of the NHS, a term which is rather misleading. These doctors can be highly experienced, well into their thirties with children of their own, mortgages and greying hair, yet are still referred to as 'juniors'. Those of registrar ('SpR') seniority have passed specialist higher exams and may even have PhDs or other research qualifications. The term is used really to distinguish them from the permanent staff working in the hospital, and to indicate that they are still in the process of building up experience before aiming for a consultant appointment.
A guide to the ranks:
Doctors are ranked in a very clear order of seniority, closely linked to how many years they have been qualified.
F1: (Foundation year one). These doctors are fresh from medical school and work under close supervision.
F2: (Foundation year two). Second year after qualifying, they are still on a programme of attachments approved by their medical school and may be marking time in a department before moving on to a department where they wish to specialise.
CMT: (Core medical trainees) These are the old SHO (Senior House Officer) grade. Two, three or four years beyond medical school they will be taking on a lot more responsibility and having to work through specialist exams.
SpR: (Specialist registrar) These doctors have chosen their speciality and are getting as much experience in their subject as they can. It usually takes five years as a specialist registrar before they can move to a consultant post.
Staff Grade: These are usually experienced and senior doctors who have not come up through the usual NHS ranks. Hospitals employ them to see patients but they are rarely given the educational and administrative responsibilities of the Consultant. Many have trained overseas and have weaker communication skills than British trained doctors.
Associate specialist: Another post where the doctors has not had a typical training in a specialty and could, for example, work as a GP for most of the week but help in a specialist clinic at a hospital some of the time.
Consultant: Most consultants do not move from the hospital where they are appointed unless they are unhappy or mistreated by NHS management. Some will be in post as long as thirty years.
How to treat your doctor:
There are many sources of advice recommending that you should prepare to face your doctor with a list of symptoms, questions and quite possibly a computer generated essay on how you have ended up in your present predicament. These are almost always a bad idea and are best put to one side.
Your doctor has a limited amount of time to deal with you. She will want to deal with the problem the General Practitioner has highlighted. Unless you have other symptoms which press the red button (generally called alarm symptoms), she will not want to take on too much of your global misery burden. It is up to her to make any links and ask the right questions to find out whether the pain in the chest you have been referred for has anything to do with the bad experience you had with shell fish six months ago.
Your doctor is also likely to know a great deal about you already before you come through the door. This is where computerized records really do help - all your previous tests and X rays are usually a few clicks away (unless you move between different Hospital Trusts).
So your doctor will not be too worried if you say very little indeed at all. A folder of internet derived information will not be of any help, nor will a verbatim account of your conversation with your neighbour or Granny. However, do bring a list of your current medications. And while you are at it, it is ever so important to also mention all the additional medications you are taking from the health food shop, internet supplier and chinese medicine man.
If it comes to the point where you are to be examined, the helpful patient will have generally loose clothing chosen so that change, keys and phones do not all spill out of pockets when in a horizontal position. Leave any embarrassment behind as the doctor will have seen far more ridiculous and extreme sights before. My own preference is that I mind not at all if the patient is grimy and workstained and I find this much preferable to highly perfumed women (and men) who have used very liberal applications of scent and cologne, which tends to persist in the examination room. Drinkers and smoker think they can hide the smell with aftershave, chewing gum, peppermints etc but they never can and this only adds to an unpleasant aroma of deceit both in the metaphorical and literal sense.
It is well known among doctors that patients sometimes conceal their real worries and, on their way out of the consulting room will make a throwaway comment which reveals why they really came. Examples such as '... and I suppose I should see my own doctor about the breast lump?'. My tip is to come out with these matters fair and square at the beginning so they can be given adequate time and not require a further extension of the consultation which will delay and upset both other patients and staff.
There remains one secret weapon the patient has at his or her disposal which will be a cheap and reliable method of getting your doctor to remember you and elevate you to favoured or VIP status: the gift. A thank you card is not only a touching way of thanking your doctor, it also has real status in your doctor's yearly appraisal. Cards and letters are much valued evidence of what the patient thinks. At the regular Appraisal and Revalidation sessions which have become a routine for doctors, they count for a lot. A bottle of wine or equivalent, while not suitable material for the Appraisal file, also will ensure the patient is more likely to be remembered and accorded sympathetic treatment the next time round.
A guide to complaining:
A common scenario in the NHS is that a patient (or relative) who has had a bad experience will follow the 'how to make a complaint' section of the hospital website and write a long and detailed letter listing every setback, problem and difficulty encountered along the way. This in turn triggers the lumbering and politically correct Complaints Department to assemble an equally long and rambling repost, humbly admitting that 'lessons will be learnt', and signed off by the Chief Executive. The complaints conveyor belt is now so refined and well oiled that the letters from the Chief Executive are pre-written on a computer template with fields added in by a middle manager. The whole exercise achieves nothing but everyone hopes it will be enough to allow the family to forget about their experiences. If a serious problem is identified with the hospital service, there is an NHS structure in place for taking this further (it becomes a ‘Serious Untoward Event’), but it is relatively unusual for these to be uncovered through a complaint.
On a more serious note, the Francis Report has been greeted with a glum reverence by virtually all in the health service. However, it is likely to take years for its recommendations to make an impact, if indeed they are remembered by the next generation of healthcare workers.
Unfortunately, the NHS complaints system regularly gets itself in a muddle. When a patient goes to PALS (the patient advice and liason office) with some questions, a comment or remark can often get funelled into the complaints in-tray and the patient suddenly finds himself labelled as a ‘complainant’. Any complaint involves input from all the consultants involved, managers, Clinical Directors, Matrons and the Chief Executive. Ironically, the person against whom the complaint is made, perhaps a ward nurse or doctor, may never even get to hear of it as complaints are dealt with as being potential deficiencies within the organization itself. A ‘rap on the knuckles’ or a telling off of a guilty individual is not a usual course of action in today’s no naming and shaming NHS.
In truth, most complaints against the NHS are down to misunderstandings, poor communication and the frequent perception that the staff are intentionally rude or uncaring. It is very often the case that relatives, rather than patients, complain and this in itself can cause difficulties regarding confidentiality issues. It is easy to lose sight of the distressing nature of illness and disease itself and feel that somehow things must have gone wrong and somebody must be at fault if all is not well.
As with a complaint to any organization there are a few very helpful rules to remember:
Dos and Don't about complaints:
Identify the one thing that really went wrong and don't get distracted by side issues.
Approach the Ward Sister or Consultant directly for a talk and leave the hospital complaints
procedure as a last resort
Decide what it is you actually want from your complaint – is it an explanation, an apology, to get somebody sacked or even to change the way things are done. Do you want financial compensation? It's surprising how few people know what they want to get out of a complaint.