A users guide to the NHS

A Users Guide to the National Health Service

Why A Users Guide?

1.The NHS is a gem it saves lives daily, all free at point of use. However it is poorly named, “National” for me infers the idea that the service you will get will be the same wherever you are within it. This is not so. How things are done can be very different depending where you are in the UK, or just between two hospitals within 10 miles of each other.

2. Because you have choices as a patient. You have the right to be treated where you want and to some extent by who you want. You also have the right to not be treated if that is what you want.

3. If you know the way round the system you may be able to get better more appropriate care.

4. Because just like children the NHS comes with no manual. Just like children the more effort you put in the more you get out.

How to Use this guide

This guide is divided into four sections:

1. How The NHS works in theory
2. How to game the system
3. Some roles and functions explained
4. Some thoughts on why getting the best for you is good for everyone.

1. How The NHS works in theory

If you are using this I’m assuming you aren’t facing a life limiting emergency right now. If you are the NHS almost always does an excellent job of keeping you alive, if that is possible. I’m assuming you have some health issues and you want them sorted, maybe advice on whether you need surgery or not. Maybe you have a recently diagnosed chronic condition that is affecting your lifestyle and you want to know how to improve your lot. Maybe you have a sick child or elderly relative and you want to know what to do for the best.

GP surgeries

In theory GP (general practitioners) are the gatekeepers of all care. Have you tried getting a GP appointment recently? Depending on your surgery, this week will be a struggle, next week more likely, some just treat what turns up and don’t make appointments. Some do Saturdays, some do not. Some have named GP’s for patients some you see whoever is available. All GP’s are very busy people doing a difficult job in a very tight time frame. Your experience on the ground will vary. It helps if you have been before, but ask questions, you are unlikely to be told unless you do.

Walk in Centres, Minor Injuries units, Polyclinics

These have been around for a good while now but not everyone knows about them. Good for minor injuries if you have one that needs looking at. For example a badly cut or broken finger or a child who has had a fever for a few days but is otherwise ok.

The care is often nurse led but these nurses are usually specialists so they know their stuff. They will often have prescribing competence or minor injuries training or both. Sometimes these centres have a GP or doctors present too.

These can be an excellent solution especially at the ends of a working day or weekends when GP’s are shut. Alas opening hours vary, as well as whether or not you even have one near you. Do some research maybe before you need these places.

The Emergency Department at a hospital (A and E)

This is the front door to a hospital, not all hospitals have one, some are major trauma centres, some just deal with fairly sick people. If you are walking in there you need to have more than a cut finger or you can expect a long wait. They will treat you based on your assessed clinical need. Even a broken limb will often be ok for an hour or three. However the person that came in the ambulance that you can’t see, probably needs help in minutes or they will die. That is why you are waiting. If you can, seek other options or live with the wait.

The Out of Hours Gp service

Does what it says on the tin. In days gone buy your GP would do a home visit at night, but those days are mostly gone. These are often based in hospitals but you cannot ring and make an appointment you will need to use the NHS 111 service. This is run by non-medical people reading a script. Oddly though some Emergency departments will refer you to them, if they think you have a reasonably straightforward problem that a GP can deal with, just to confuse the issue.

Specialities and Consultants

These are the people in the NHS that deal with anything that cannot be sorted out by any of the people above. You get access to them via what is called a referral. This is still more often than not a letter written by somebody from one of the people working in one of places above that says basically, “This one is beyond my skills can you help”?

Consultants are well qualified doctors. Amongst them you find surgeons that do knife work. As well as people who recommend a whole range of other therapies. Drugs, monitoring, lifestyle changes or sometimes just waiting, it depends what is wrong with you.

Specialities are mostly what hospitals do.

Pharmacies

Many Pharmacists are now full prescribers. If it is no more than a cough and cold, or an upset stomach a pharmacist may have easy access to the medication you need and be happy to dish it out. If they are out of their comfort zone they will refer you on. This saves you time and shortens queues in A and E. Ring and ask first if you are unsure.

Community Care

District nurses, midwifes all the things for those that can’t get themselves to a hospital or surgery. A huge growth area, we are all getting older.

All the other things

By this I mean all the services you need to make all the above happen.

So to pick on just a few, catering, pathology, microbiology, X- Ray, blood testing, cleaning, payroll, A mortuary, heat and light, record keeping, drug buying and control, commissioning and planning.. There are many more services in a  hospital, healthcare is a complex beast.

2. How to game the system

Your first problem is often how to be seen quickly. I would argue actually how to make sure you seen by the person that can help you the most, in the shortest time. The runaround is stressful.

Firstly you have to decide if it is an emergency?

If it is (you think you may die) call an ambulance, but more often than not if it is that serious somebody will be calling one for you. You will be heading to the Emergency department. If it is really life threatening you are off to a major trauma centre in a big city. They have an hour to get you sorted, they won’t be messing about.

If you think you have broken limb and no bone is poking out and you are in pain but mobile with help. Well you need an X -Ray and a check over, but many minor injuries centres can do X-Rays so worth thinking about if you have one near by. They are often quieter than full blown emergency departments. if not you are off to the emergency department with everyone else ,for a bit of a wait

Go Early,

This is a good tip if you did something of have started feeling unwell and its non life threatening (you think). If you still think it needs the once over you could do worse than go to A and E early in the morning. Or phone your GP as soon as they open to see if you can be seen. This is true for walk in centres. With the exception of a Monday morning when everyone has been sat around over the weekend with a bit of something that they now realise is going to keep them off work. Monday mornings are usually busy, but they tend to clear the bulge by mid afternoon. Oh and if you can avoid A and E after midnight Friday and Saturday do. It will be the human zoo as our love of alcohol comes to the fore.

See a practice nurse.

If you ring the Gp and you can’t get a Dr many surgeries have practice nurses. These people are often Masters qualified, very experienced and can often solve your problem. Use them.

Ask Questions

I am amazed by the number of people that unquestioningly progress through their health problems never asking for an explanation from the care givers they come across.

You need to know the following, ask always and ask often. Good practitioners will answer all these questions often before you ask them, but sometimes they are very busy, sometimes they are just not great talkers. Remember they work for you and you need to know.

What is happening now?

What happens next?

Why do I need this test?

Why do you think this is the right thing to do?

What are the side effects of this drug?

What are my other treatment options?

What if we do something sooner?

What if we wait?

When will I hear?

How long is the waiting list?

What is my chance of Death?

How many people are alive after 10 years?

Do your Homework

If you get to the stage where you have a diagnosis you can check out the research on your problem. For example all surgeons publish data on their success rates and it is risk adjusted, more to the point it varies quite a lot. Some consultants have favourite places they refer too. Often this is nearby but sometimes you would be better going further afield to get a better surgeon or a better more modern procedure. You can choose but if you don’t do your homework you will take what is offered whether that is merely good rather than the best available, for which you need to travel another 40 miles.

Bear in mind consultants have long careers and whilst many retrain throughout their practice, sometimes people who start off cutting edge are looking pretty out of date as they enter their late 50’s. Many consultants practicing now were not tested on their ability to communicate with patients believe it or not, but they are now. A young consultant in their mid 30’s to mid 40’s is often as good as you can hope for but each case on their merits.

Ask them questions if they are happy to answer, or if they answer all your questions before you ask them, you are probably in safe hands.

Talk to the Ward or Secretary

All consultants have a secretary as the consultants are busy operating or testing or running clinics. The secretary will know your operation date, may have your results or may just be able to tell you why you haven’t heard. If you can't get a result over the phone (secretaries are busy too) use email you will often get a result this way.

Sometimes if you are waiting for an admission or you are waiting to hear how someone is doing ringing the desk on their particular ward is the easiest way to find out. Don’t just ring the hospital’s main number, find the ward number somebody should be able to help. Be prepared to be a close family member they don't often give out details otherwise.

Ward Rounds

If you find yourself on a ward, these are the daily opportunity when your care gets discussed and reviewed. Sometimes your consultant will be there sometimes other doctors and nurses. Some doctors talk to you, some just each other but try and get involved. Ask questions and be as vocal as you can, remember they are curing you, you are part of the process. If you can’t get a word in, talk to your nurse straight afterward. The discussion even a decision to do nothing different, may been made. Equally unless you take a turn for the worse don’t expect much to change from the agreed ward round plan until tomorrow.

Complain

If things are not moving, if you have done your research and you have still got a referral that you think is wrong, or if you think you were misled or mistreated, complain. To start with go via the hospital's patients satisfaction (sometimes PALS) service. This often gets results and quickly. If that doesn’t work, write to the chief exec of the hospital but bear in mind that complaints that; your tea was cold, your dinner was late or that your appointment was and hour overdue are likely to be met with a polite but justified Foxtrot Oscar.

3. Some roles and functions explained

Back in the day it was simple. Doctors made the decisions, did surgery ran clinics and dished out specialist procedures. Nurses did what they were told by doctors and also everything else. Some support staff did other stuff (x-ray, bloods, labs etc)

These days the lines are much more blurred, this is a good thing. It is also harder to understand. Always read name badges and if they don’t introduce themselves ask.

As a very rough guide doctors are dressed by boden looking like they are going to the theatre or are in scrubs looking like they have just escaped from an operating theatre. Nursing staff almost always wear some sort of uniform, the darker it is the more senior and capable they are.

Doctors

There are all sorts of different types they have all been to medical school. Other than that there is a world of difference:

GP

General Practitioner the decathlete of healthcare. Good at everything but genius at little. Spends a lot of time telling people with colds they will be alright in a few days. Also has to spot the early signs of cancer, heart disease and a whole host of other difficult to spot, dangerous conditions as well as take responsibility for the health of their patients. A tough job and GP’s are really busy at the moment.

Consultant

A super specialist. Maybe a surgeon but one type: hands, heart, brain. Or a pediatrician (kids) or Arthritis, or Cancer (again one or two types). Each hospital specialism will have one or usually more consultants. They make decisions with you about your care at the highest level although depending on your problem you may speak to one of their team. Even so the consultant will be responsible for your care. Many doctors make consultant around thirty, they know their stuff. They are very powerful within Healthcare. If a consultants says paint them yellow and wait until Tuesday this will happen.

Consultants also develop their specialism locally and get involved in clinics, staff teaching and often other hospital wide decisions. It is a big job, but they get well paid.

Should you want to argue with a consultant's opinions best to make sure you know your stuff. However even if you are wrong a consultant has to listen and act on what you want even if it is wrong. You are the most powerful person in all of this process. Unless of course you have lost your marbles (this is not the medical term I hasten to add), when they can act in your best interest. 

Anesthetist

The person who keeps you alive during a general anaesthetic. An important job I am sure you will agree? Expect to meet them before an op. Hope to never see most of what they do for a living or something has gone wrong.

Registrar

A consultant in training. Often young, keen and super efficient. As they are fairly soon going to be consultants themselves, they are often given some or all of patient's care especially at weekends or evenings. A registrar may finish your operation off when the consultant has done the tricky bit. If it is a straightforward procedure they may do it all. Often you will see the Reg much more than the consultant so ask them the questions.

Staff Grade

Not all doctors make consultant or need to, there are plenty of staff grade doctors around for. They just do the work so no teaching focus. Still they will be a specialist in their field and often have  a wealth of experience to bring to the table.

F2 (SHO)

A second year doctor in training, by this point they are getting some experience and being allowed some freedom. Often do a lot of the basic general doctoring that doesn’t need a Reg or a consultant but will refer up the tree if they are unsure.

F1 (Pre reg)

A doctor out of med school doing their first year in training. Depending on where you catch them in the first year they may have a head full of medical school and be trying to hide the fact they are terrified about dealing with patients. Or you may catch them when they are up and running and starting to realise all that swotting for exams was worthwhile and they are glad they chose medicine over law. The doctor equivalent of an army private


Med Student
A medical student in training, often keen to watch your care or procedure of generally get involved somehow. They should always ask permission or the doctor who they are with should ask on their behalf. You don’t have to agree to let them but if you don’t how are we going to bring on the next generation of medics?

Specialist Nurses (ENP ACP ANP Practice Nurse)

Lots more of these about these days. Often sister or senior charge nurses (boy nurses are common these days) who have progressed their career by doing a masters degree and conducted a two year training program sometimes much more.

They see patients, prescribe drugs and treatment, request and interpret X-Rays and bloods, provide care, dress wounds, assist consultants. In many ways they are a doctor's equal arguably better. They came though a patient focused care route so are good at talking to patients, other nurses and doctors. They are often vastly experienced so bring a mix of knowing how stuff works and how to get stuff done to the table. If you offered me a specialist nurse or an F2 for my care I’m taking the specialist nurse.

Sister, Senior Charge Nurse

Nurse managers, often forming the bridge between the nursing and doctor teams. Making sure beds are empty or full and getting people in and out of the ward or department. They still regularly get their hands dirty when things are busy or they are covering breaks, but probably also have an office where they wade through paperwork and try and work out how to make their particular bit of the behemoth that is a hospital run more smoothly, whilst planning staffing rotas and nurse training. Often to be seen driving a telephone at the ward desk trying to get someone into another bit of a hospital for something they need urgently.  Often in Navy Blue

Nurses

Hospitals are full of them. They change your dressings, hand out your medication, monitor your blood pressure oxygen sats and heart rate (OBS) and look out for signs of things going well or badly. If you are on an intensive or high dependency unit your will be being nursed in a ratio of 1 to 1, or 2 to 1 and your nurse will be taking blood, watching your urine output ,making sure you are in no pain and responding to anything out of the ordinary and generally helping to keep you alive. The level of the decision making they can undertake will depend on where they find themselves working. Some have a lot of freedom (in A and E for example) but they are certainly no longer doctors handmaidens.

These days and for a good few years now nurses are degree qualified and probably see being a staff nurse as a start of a career in nursing. However despite the increasingly technicality of their role they are patient focused and are completely the wrong person to ask for a cup of tea, as they really are busy.

HCA - Healthcare Assistants

The foot soldiers of Healthcare they do the work. If a nurse monitors your OBS, the healthcare assistant takes them. They change your bed linen and some take your blood and bring you things to wee in. They do the work on which everyone else relies to make decisions.

Host(ess)

Some hospitals have dedicated staff to feed you and keep your water topped up. They are definitely the people to ask for a cup of tea.

4. Some thoughts on why getting the best for you is good for everyone.

I hope this guide helps you get the care you want and need, when you need it. Some might think the idea of gaming the system is cheating or putting yourself before others and that that is wrong. I disagree. If the health service has problems, I don’t think it is with the quality of care. Sure there are the occasional horror stories you see in the papers, but these, like unicorn tears are very rare indeed. Mostly the overwhelming majority of the time the National Health Service provides good or world class care. If there is one problem it is that communication is sometimes poor between bits of the service and between the service and patients.

Everything I have suggested is about you taking responsibility for your own care, about you understanding a complex system and making sure you interact with the right part as effectively as possible. If you do this you may well remove yourself from a waiting list or queue somewhere or just progress faster. This will improve the overall efficiency of the system and everybody benefits. We need patients to be proactive and informed, it saves time, it makes sure you are involved in decision making rather than just in passive receipt of care which someone thinks is best, these are good things.

Finally

I am sure have missed as much as I have included here. I'm not medical  but I know a few people who are, my grammar is shocking and I have just had heart surgery. Any comments try dave@princehouse.co.uk