Counting the NHS
“On a scale of 1–10, how bad is the pain right now?” asked the nurse pointing at my wrist as she checked my blood pressure and pulse.
“No more than a three,” I replied. “That is, if I benchmark as a ten the moment when my wrist was manually twisted back into shape in A&E the evening of my accident.”
The nurse exclaimed, “Oh, that was you! I was one of the team that did the twisting. It was quite a mess and took four of us to get it right and into a cast. Without that, they would have to break the wrist again when they operated on it. You did swear a lot, so I am guessing that ‘ten’ was painful!”
I didn’t remember the nurse but I certainly recalled the moment she and colleagues had manipulated my wrist. I had assumed only two people had twisted my broken and mangled wrist back into shape, not four. I was in a state of shock so wasn’t keeping an accurate count of people in the room in A&E. After the nurse’s comment, I made a mental note to adjust my estimate of how many people had cared for me since my cycling accident. And I apologised for my bad language.
What’s in a number?
Based on the new information, my revised estimate was that a total of 64 NHS staff had cared for me before I was discharged from hospital.
The NHS is incredible as a system for managing information about patients to support high-quality care. That system mobilised for me from the moment the first ambulance arrived and it continued throughout my time in hospital. This aspect of the NHS as a system often gets less attention than praise for the care, professionalism, and humanity of the staff. Without good information management though, the overall care is far less effective.
A chessboard has 64 squares. Visualise a chessboard and imagine that many people having the right information to know what to do; each person performing their role efficiently and effectively; and, sharing information as patient care and tasks are passed from one square to another. It is a formidable challenge to get right. It was done spectacularly well in my case.
Accident
This all began with a bad cycling accident when I crashed into a car on a Friday evening ride. Two men helped me initially and called 999 while a passing nurse (herself a cyclist) lent a hand, holding my head still until an ambulance arrived. The actions of that nurse might have been crucial — it turned out that I had a chipped vertebra in my neck. Her actions might have prevented further, possibly catastrophic damage.
The first ambulance to attend the scene happened to be passing and stopped to treat me. A second ambulance, which was responding to the 999 call, took over and drove me to A&E at Cramlington Hospital in Northumberland. If I do not count that first nurse who held my head — because she was not working at the time — the two ambulance crews represent the first NHS staff who cared for me.
I stayed in A&E for most of the next 24 hours, occasionally being taken for X-rays or CT scans. I was eventually transferred to a ward and waited for an operation on my broken wrist a few days later. It was shattered and needed a metal plate inserted to fix it. As well as the wrist and chipped vertebra, I had a fracture on my other shoulder and arm. The shoulder had dislocated in the accident and the top of the humerus was chipped and there was also a fracture extending down to my elbow. Somehow the dislocation had corrected itself during the accident, leaving the humeral head damaged but in place.
A broken neck and two broken arms summarises my injuries. I wince at this description, but it is basically correct. (We discovered much later that my nose was also broken, though no one seems to care about that.)
Aside from my wrist, the other injuries are expected to heal naturally, though there are murmurings about my shoulder which is being treated “non operatively at the minute” (emphasis added). The neck is being reviewed next week and, hopefully, will have healed enough for the Aspen collar to go. After six weeks of trying to sleep sitting up because of the discomfort, I am rather tired.
I have made a conscious effort throughout not to google my various injuries. Whenever I give into temptation, it scares me and I quickly stop; the vertebra being merely chipped seems a very lucky escape. It could have been so much worse — I have full use of my legs and arms, something which was checked and rechecked many times while I was in hospital, as well as since. I hope this luck continues.
Keeping count
Instead of reading about my injuries, I decided to surrender myself to the professionals, trust their judgments, and ask questions but avoid doing my own research. In contrast, I have tried to pay close attention to the number of people involved in my treatment. My curiosity was initially piqued by the constant flow of people who came to see me in the ward. The list of tasks seemed endless and I decided to try to keep a rough count through the haze of painkillers.
The many painkillers had to be administered; my (too short) bed needed to be adjusted as I could not lie down or move; my neck collar needed checking; a device to let me suck water through a drip was needed, because I had no use of my hands; my partner Jen needed advice on how to feed me until my hands worked again; a surgeon needed to decide whether to operate on my shoulder as well as tell me what they were planning to do to my wrist; and so on. To the numbers involved in these tasks, I needed to add those who had helped in the first hours at the roadside and in A&E. I tried to replay in my mind the first 24 hours and the staff involved (four ambulance staff, two for each X-ray or CT scan, the doctor making the initial A&E assessment, the nurse who fitted my neck collar, the orthopedic surgeon who visited me, etc).
I continued counting when I was taken for my operation. I am not certain how many people were in the operating theatre even though I only had a local “block” aneasthetic for my forearm. A screen prevented me from seeing my wrist being operated on, meaning I could not count exactly. I know more precisely that a team of four physiotherapists and occupational therapists visited me the day after the operation to get me ready for discharge.
The final nurses who helped me get ready to leave took the total to 64. I have tried to be conservative in this calculation and, as part of this, have only included staff who directly worked on me. I have not included, for example, the consultant radiologists at a different hospital that assessed the CT scan of my neck. I am confident that the final figure is at least 64.
Managing information
Throughout all of this, I did not have to fill in a form, never once answered a questionnaire, did not get a quote or an invoice, nor saw an estimate of costs. We all know this is a feature of emergency care in the NHS — the concept of free at the point of use and without question or hesitation. It bears constant repetition because it is so profound and profoundly impressive. Alongside this though, there should be more appreciation of the way in which the information challenges of providing such emergency care are managed.
All of those 64 NHS workers had the right information to act speedily and effectively and do so seamlessly. That is truly remarkable. Anyone who has dealt with messy customer services in the private sector — at a bank, say, or with a public utility — and had to repeat information endlessly about an account or a problem, should marvel at the efficiency of the way the NHS manages this. Even if the NHS doesn’t always get this right, my experience shows that it can work wonderfully well.
Whose impact?
I have spent part of my career as an economist and analyst thinking about the impact of charities’ work. Questions in this field often focus on how to define and measure impact, as well as who should get credit. The approach has become more mainstream among charities, though it can still be a little contentious.
One can apply this thinking to my care. We can define the full impact as a successful recovery of the patient. That should properly include both physical and emotional recovery. Each and every one of those 64 NHS staff contribute to these. The collective impact comes from all those 64 staff. It is the system, with all the individuals in it and including the information management, that delivers the successful outcome of recovery for the patient.
Reasons to be grateful
There are several reasons to count the number of people who helped me. The first is to feel a sense of gratitude. Gratitude for the kindness of so many people who helped me navigate my accident and the early stages of recovery. That kindness was mixed with professionalism in everyone. So, I feel gratitude to the NHS and to the individual staff. I also want to recognise my good fortune. I look on course to make a full recovery thanks to the efforts of so many people. Counting the number involved helps somehow.
I also wanted to reflect on the way that information is managed and flows within a system like the NHS. My day job is running a charity that supports other charities and community groups across London. Ensuring that information is shared smoothly and efficiently across London is a key part of this. Because of this, I am obsessed with the role that information flows play in making systems work well. Seeing for myself how the NHS manages information was fascinating.
Above is a fairly early picture after my discharge. The beard is thicker now as the neck collar makes shaving impossible. It is unclear whether the beard will survive the removal of the neck brace. Others in my life will probably decide. Central in this, my partner Jen became my carer overnight when I was discharged. There is little preparation or support for this — which is where the system falls down a little. Jen also had her own information challenges as she had to tell my wider family about my accident, including my daughters, mother, and friends. Cue yet another WhatsApp group to send updates!
Ever higher
Further hospital trips continue to add to the total of NHS staff; as do GP receptionists sending prescriptions for painkillers; and the district nurses who visit three times a visit to adjust my collar; and physiotherapists trying to help me get more mobility in my arms.
I don’t need to count the final number of NHS staff. I know it is very high. Sixty-four seems a big enough number to stop counting. Whatever the final figure, I am grateful. Not just for the care — its quality, the professionalism, and the humanity. But also, as part of this, for the way the NHS managed information to make this care possible. It is a relatively unsung feature of the NHS. I want to celebrate it.
Martin Brookes
5 July 2023
To staff at Cramlington Hospital and the Northumbria Healthcare NHS Foundation Trust, a heartfelt thank you. And to Jen too. You are all awesome.
