Tag Archives: Hospital

Much of what’s wrong with healthcare is in the consulting room

It’s not that complicated. Not really. So where do you look for pathology? Inspection, palpation, percussion and auscultation. How does it look, how does it feel, how does it sound and what do you hear when you know where to listen closely. I’m talking about healthcare. Take a helicopter ride through your business.

Access

What is the route to your service? Where is the delay? How long do people wait in the waiting room? How do you know? What do you know about the people who use your service even before they are seated in your waiting room?

Greeting

What happens when people call or arrive in person? What message is conveyed?

Welcome we’ll do our best to help you today OR you are lucky we are ‘fitting you in’.

Just stand there- I’m dealing with someone on the phone.

We have no time- go complain to the manager/politician/ bureaucrat-consider yourself drafted to the cause.

Hold the line. We are dealing with something far more important but your call is really important to us so just listen to how good we are as conveyed by our prerecorded message.

Associated with that is what is perceived about your attitude that is not verbalised?

Look at ALL these posters and the many ways you can be helping yourself instead of wasting our time.

People vomit and pee while they wait so the seats have to be cleaned with detergent. Plastic is the best option.

If you want a drink go buy one at a cafe.

We rely on donations for our toys and magazines- we don’t have to provide anything OK? Now if you don’t like the stuff just watch Dr. Phil.

What do you mean you have been waiting a couple of hours? This isn’t McDonalds now take a ticket, sit down, shut up and wait. And turn off your phone so you can hear the old lady at the desk who has an embarrassing problem.

Communication

How long is the meeting with the provider? How does that meeting unfold? What is conveyed during the meeting?

Welcome- I’m so sorry you are not well. Tell me what happened? OR I haven’t got long what do you want exactly, spit it out be quick about it I need to get on with the next guy. Didn’t you see the queue out there?

I’m the important one around here- you are lucky I’ve chosen to be here today. Let me tell you about my holiday, my kids, my new car. It’s fascinating really!

Room 5. Quickly. Never mind my name.

Test/ Referral and Prescription

What action is taken at the consult and are you confident that is the best possible action?

I don’t have time for talk- have this test and take another day off to see me next week.

I don’t have time for you to take off your umpteen layers- go have a scan.

The rep told me this works- I only have to write a script.

If you want to get better take my medicine/advice/ referral or get lost.

What medicine do you want? How do you spell that? Tell me slowly I’m writing it down on your script.

Outcome

What proportion of people takes your advice/medicine/test? How many people stopped smoking? How many were triggered to lose weight? How many are addicted to prescribed medicines? How many were prescribed treatment or tests that were not indicated? Where’s your data? What are your plans for dealing with this?

Team

To what extent can you say that when people transition to another healthcare professional either on site or elsewhere that the relevant information follows them? Is everyone on the same page with the same patient?

All of this matters. All of it. Some of you can fix tomorrow. No need to wait for another round of healthcare reform. No one said it was easy. And whatever their business the best don’t compromise.  A lot of what can be fixed in healthcare takes place behind the closed doors of the consulting room.

Picture by Daniele Oberti

The welcome rise of alternative providers

Two weeks ago an 80-year-old waited without food or drink for 14 hours in a Dublin city emergency department having fallen in her local supermarket. She was black and blue from head to toe a response to the call of gravity when she was launched off a faulty escalator. She was ‘triaged’ and seated next to drunken revelers who also managed to injure themselves on that fateful evening. She was seen for all of 10 minutes by a medical student and then briefly by a doctor who recorded that her visual acuity couldn’t be assessed because she didn’t have her glasses. With that, she was sent home with her granddaughter and asked to return a couple of days later when she again waited another 9 hours for a five-minute consultation presumably so that the doctor could make sure she hadn’t really injured herself and wasn’t going to sue the hospital as well as the supermarket.  I know this person and read the discharge summary even though her daughter and I live on the other side of the world. As far as we know the provider believes we should be thankful because they are very busy and at least ‘someone’ saw her.

What’s it like to be your patient?

  1. How long do your patients wait?
  2. How are they greeted on arrival and how do they feel about waiting?
  3. What do they do while they wait?
  4. How long do they see you on average?
  5. What do they expect from the visit?
  6. Why do you order tests? What difference do these tests make to the outcome?
  7. Why do you prescribe those drugs? How many people take them as prescribed?
  8. Why do you ask them to return for a review appointment?
  9. Why do your refer them to someone else?
  10. What do they tell their family about your service?

No business would survive without a handle on this information. Arguably some sectors of the business of healthcare only survive because of a monopoly.

A newer take on the organizational environment is the “Red Queen” theory, which highlights the relative nature of progress. The theory is borrowed from ecology’s Red Queen hypothesis that successful adaptation in one species is tantamount to a worsening environment for others, which must adapt in turn to cope with the new conditions. The theory’s name is inspired by the character in Lewis Carroll’s Through the Looking Glass who seems to be running but is staying on the same spot. In a 1996 paper, William Barnett describes Red Queen competition among organizations as a process of mutual learning. A company is forced by direct competition to improve its performance, in turn increasing the pressure on its rivals, thus creating a virtuous circle of learning and competition. Stanford Business

Certainly, the 80-year-old had no option but to go to a state hospital emergency department because there was a very real possibility that she had fractured something coming off that escalator. The hospital manager might say in her defense that they have no option but to offer the service as described, but where is the data to demonstrate that it is the lack of options rather than a lack of interest or talent in managing one of the most important services the state is charged by taxpayers to provide? The monopoly may be around a little longer when it comes to life-saving treatments but what about primary care? If this 80-year-old can wait 14 hours to be seen by a medical student there may be real scope for the service to be provided by someone who is qualified, will see her much sooner and offer her a cup of tea while she waits for the X-rays to be reported. What about the scope to provide better than what you offer?

Picture by Toms Baugis

Why general practitioners are crucial to the economy

The odds of experiencing an event that will descend you briefly into your own private hell are significant.

These odds are much greater than the odds of getting something that requires heroic intervention:

Good news = You are more likely to catch a cold, sprain an ankle or have a runny nose than suffer anything more serious.

Bad news = What happens if you get one of the aforementioned ‘minor illnesses’.  I am living with fractured ribs this week. This is what happens:

  • You are told there is no treatment and no definite recovery period.
  • You can’t tie your own shoe laces, take off your socks or dry your back after a shower.
  • You can’t push open doors.
  • You can’t get out of, our turn over, in bed.
  • You dare not sneeze or pick anything off the ground.
  • You get persistent headaches because of paravertebral muscle strain.

The pain will get worse before it gets better. So at first you might go to the emergency department (ED) because your family will insist. At the ED you will be X-rayed. You will be prescribed analgesia and advised to take time off.  A day or two later in increasing pain you will toy with the idea of going back to hospital just in case they’ve missed something.  The codeine will cause constipation making things worse. Some doctors will advise you to take tramol others will advise against it. A specialist might recommend intercostal nerve blocks (anything looks like a nail when you are armed with a hammer). The cost of getting medical attention will mount. What you will need the most is symptom relief and a greater sense of control. Your only hope is a good GP.

In desperation you might consult YouTube for any useful hints on how to recover. This person has clearly never experienced rib fractures. I hope no medical student thinks this is how to approach the examination of anyone with this condition. On the other hand this person clearly has.

Health economists tell us that the increased costs in the healthcare system are due to unnecessary tests and treatments.

On average, a 50-year-old now is seeing doctors more often, having more tests and operations, and taking more prescription drugs, than a 50-year-old did ten years ago

You are at greater risk of ‘minor illness’ than any other illness. Yet we know that is when we are likely to request tests and treatments in the vain hope it will hasten the recovery. Good GPs  reduce this morbidity as well as the cost of caring for people when time is the only treatment.

This week we launched the Journal of Health Design. The scope of our journal is to support researchers who are developing innovations inspired by the patient experience of healthcare. This was also the week that the Royal Australian College of General Practitioners supported our team to conduct research that aims at supporting GPs in consultations with people with viral infections when antibiotics are not indicated.

Picture by Matt Pelletier

The failure to communicate is costing us billions

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The Weekend Australian headline today, Sunday 24th April 2016 declared that

Healthcare waste costs $20bn a year

According to the graph on the first page of the paper there were 105-110 General Practitioners (GPs) or specialists in 2004. Although the number of GPs per 100,000 population has remained static there are now more than 130 specialists per 100,000 people . Therefore the rising cost of waste in healthcare runs parallel to the increase in specialists in the population. The source is quoted as the Australian Commission on Safety and Quality in Health Care.

But there is nothing new about this story. This trend was demonstrated in previous decades. More primary care equals lower costs the formula isn’t complex. Reading the papers today we recall the late Barbara Starfield’s words:

Six mechanisms, alone and in combination, may account for the beneficial impact of primary care on population health. They are (1) greater access to needed services, (2) better quality of care, (3) a greater focus on prevention, (4) early management of health problems, (5) the cumulative effect of the main primary care delivery characteristics, and (6) the role of primary care in reducing unnecessary and potentially harmful specialist care.

The disappointing thing about the accompanying newspaper commentary was the suggestion that the solution is political. The journalistic analysis is that powerful lobby groups have managed to influence policy to the point where there is subsidised over servicing of the population. Specifically prostatectomies, colonoscopies, arthroscopies, cataract surgery, hysterectomies and CT scans.

In a country where general practice remains the gatekeeper to specialist services we need to figure out how we might be able to tackle the problem for the sake of the economy. The solution is to remain circumspect about another quick fix because we have learned that politics and the need to be popular with the electorate rarely delivers anything like a lasting solution.

In medicine people are referred or persuaded to have treatment or investigations and under the ‘big data’ is the story of ineffective consultations. One where either the patient is not examined or an adequate history taken, or where the risk and benefits are not explained to the patient in a way that informs the decision. After all if that were not the case which patient at very low risk would chose to have a colonoscopy?

What is the difference between managing a request for an antibiotic for a cold and managing a request for a CT scan for mechanical back pain? To those who are cynical about the chances of getting the message heard we might say wait. When there is sufficient pain the bureaucrats will beat a path to your door. There is no solution as effective as improving how we communicate with patients, anything else will paper over the hole, no the chasm, in the budget.

Picture by Christopher Blizzard.

Why healthcare outcomes are resistant to policy change

13799802965_b07db37bf2_zAfter every match, the cricket coach gives feedback about how the match was won or lost. Whenever the team wins it’s usually because of high scoring batting, or a great performance by the bowlers. However, when they lose there’s almost always one reason—poor fielding, dropped catches, easily conceded single runs and inaccurate throws.

In medicine surgeons are the batsmen, in most games they are seldom in play for very long. When the surgeon gets involved the crowd holds its breath for something magical to happen and when it does they celebrate with ‘Mexican wave’. Physicians are akin to bowlers, trying different deliveries, aiming to make it difficult to concede runs, patiently waiting for an unforced error. Occasionally screaming at the umpire for a decision in their favour. In the limelight an over at a time.

General practitioners are the fielders, rarely flamboyant and hard to tell apart. Constantly moving across the field, often to simply return the ball back into play. Standing for hours in the hot sun, occasionally chasing a ball to the boundary. Always trying to limit the damage. No matter how good the batting or the bowling is, if those in the field are not fully engaged, or solving problems creatively, if they are not intuitive, or working for the common good, without waiting for instruction after every ball is delivered then the game is lost.

As a primary care practitioner I am aware that most of the patients I see won’t have life-threatening pathology, but occasionally I’ll get a chance to make a game-changing difference, and on other days, my patients feel safer knowing that I am there. I don’t need to make any fancy moves, most of the time what I do is simply ensure that I nip things in the bud.

In medicine, most people consult a general practitioner and not a surgeon. That’s where innovation has the scope to make a difference to most people. Without reference to the practitioners who work at the coalface no amount of policy change is likely to make a difference to outcomes. That’s because fielders can’t do their job with one hand tied behind their back or by ignoring the evidence of their own eyes, or by focusing other than on the ball. According to the experts good fielders:

  1. Don’t move. When the captain puts them somewhere they stay there until they are moved again.
  2.  Show confidence. Looking confident in the field can save many runs.
  3.  Will throw at the stumps whenever there is a chance.
  4. Back up.
  5. Want to get every ball.
  6. Are close enough. If they are on the boundary their job is to save fours so they stay as deep as possible without giving away two runs if they can.
  7. Know themselves. If they have a setback in the field, they are aware of how they will react to it.

These simple rules tell us that it is imperative to work with the fielders if the team is to win the match. Failing to do so, like failing to work with the doctors most likely to come into contact with patients leads to frustration. The emotion that most funders experience perhaps because they do not understand the business of doctoring. We need to reframe problems in healthcare as a failure to engage with front line staff.

Picture by Lawrence OP

The bean counters of BoGIn

5085594028_fc5d378a40_zThe bean counters at BoGIn (Bank of Good Intentions) noticed that some people came to the bank to get mortgage advice and others for personal loans. In fact there was a lot of money to be made by persuading people to borrow money. So they decided to make some reforms. A memo was circulated informing staff that customers will only be able to deposit money in the afternoons- it was to be called the ‘deposition clinic’. Similarly customers would only be able to make withdrawals on Wednesday mornings. Additionally this service would be manned by the most junior clerks who must have all their work checked by the bank manager who would also spend the day at meetings reporting his branch’s performance on key performance indicators.

Customers who withdraw their money are not good for business.

Bank tellers were ordered to ask every customer to fill out a form documenting how much they owe other banks. Customers must always do this before tellers can attend to any other reason the customer came to the bank. Forms must be completed with a black pen and the signatures witnessed by two independent adults. Bank tellers would earn a bonus every time a customer takes out a loan and would accrue points towards promotion if the customer takes out a mortgage at 5% above the cheapest rate on the market.

The bank managers and their staff were shocked. How was this to be achieved? However the bean counters pointed out that the shareholders required the staff to be accountable and there was a need to increase profits by at least 25% this year. A percentage agreed by the committee of bean counters advising the shareholders.

But we are doing so well. The bank makes a hefty profit and our customers are among the most satisfied in any industry. We offer a service. We listen to our customers. We try to help our customers achieve great things that keep our economy afloat.

The bean counters were not impressed and threatened to force managers to be recertified every year or lose their right to bonus payments. Many managers have since found alternative employment. Recently the CEO of BoGIn attended her branch to deposit a cheque. She queued for hours before she was first asked to complete a form documenting her debts and given a brochure on mortgages. Then she was informed she could only make deposits in the afternoon so she had to return the next day. The bean counters have been sacked and were last seen at the department of health next door.

Picture by DaMong Man

Not disordered machinery

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When we think of hospitals we think of a sterile environment. It is assumed that it is a place where your health and well being will improve. That each of your senses can be assaulted in all manner of ways and that because of this, rather than in spite of it, you will get better.

My 30-something year old brother-in-law died in hospital six years ago to the day. He died alone, confused and incontinent. Separated from his beloved daughters and in isolation. The lymphoma that riddled his body was undetected as immunosuppressive drugs stood sentinel over his new kidneys. Everything that could be done was done. He was a young man and the oncologist was determined that he would receive aggressive chemotherapy until she decided that he was beyond her help. We could only watch as he lost his dignity for the slim chance that he might walk out of the place alive. In reterospect it was hard for everyone. He was not ready to die and nor were the medical team prepared to call time. He might have beaten the pathology but it is the journey and not the destination that was the worst aspect of the experience.

Medicine has advanced so much in the last few decades. We now have many life saving drugs or procedures that can be deployed in what were previously hopeless cases. But what hasn’t changed much is the experience of being hospitalised. In the world of blogs and social media we can read the accounts of patients without having to experience them for ourselves:

A man in his fifties who was admitted to hospital with autoimmune haemolytic anaemia, a complication of chronic lymphocytic leukaemia (CLL), first went into a general cancer ward as the haematology unit was full. The ward was depressingly full of very ill old men some of whom died while he was there…..Living in isolation for long periods could be difficult for people who were not used to being alone. Some had felt lonely, frustrated, hemmed in or bored…..Some people found their room pleasant, peaceful and well equipped with television, phone, hi-fi and ensuite bathroom. Neil said his was better than some hotel rooms. Jim said the showers were awesome. Others found their room depressing and had problems with temperature regulation or hygiene. Some people personalised their room with possessions from home. Gilly arranged hers with kitchen, study and reading areas. Brian was disappointed to have no internet connection so he got a modem that would connect his computer via his mobile phone. Some hospitals restricted what people could bring in from home. Healthtalk.org

As new hospitals are built de novo or to replace aging and outdated institutions we have an opportunity to build new ones that facilitate the innate healing powers of the human body. Healing is ‘the result of intention, personal wholeness, relationships, healthy lifestyle, collaborative medical care, healing organizations, and healing spaces’ (The Samueli Institute). The optimal healing environment addresses issues such as: ‘Connection to nature, options and choices, positive diversions, access to social support, reduced environmental stressor, private and  adaptable rooms, less noise, better wayfinding, lounges and waiting rooms with a purpose’ (Terri Zborowsky and Jo Kreitzer). None of this requires a Nobel laureat to spend a lifetime ‘proving the case’. What it does call for is the determination to ensure that hospitals are a place where it is joy to be born, a refuge when you are ill and somewhere to die in dignity when there is no other option. Humans are not disordered machinery to be parked on a ramp in public place while technicians attend to their under belly. If they are treated as such when they are ill their chances of recovery are diminished. Rest in peace Johnny.

Picture by CJ Sorg

The case for innovation up close and personal

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In the same week that my colleague drew my attention to the new book ‘ The patient will see you now‘, I became part of John’s story. I quote from the book:

Doctors are still labeling patients as difficult. Patients are typically unable to see, let alone keep or contribute to their office visit notes about their condition and their body that they paid for, Frequently they have to consult multiple doctors for the same condition. It may take weeks to get an appointment. The time with the doctor is quite limited, typically less than ten minutes, and much of that is without eye contact because the doctor is pecking away at a keyboard.

John (75) was born and lives in Dublin. He has the generosity of spirit that made Ireland what it is. A working man all of his life he lives to walk to the shops on Saturday morning. Two years ago he had a bilateral knee replacement. In the past six months he has become severely disabled with back and hip pain. He now walks with crutches and spends most of the day in a chair. His aging wife has to help him put on his socks, a friend ferries them to the shops in his taxi once a week. He is in constant and relentless pain. He attends a pain clinic and visits his general practitioner on foot, a hour long walk on his crutches every week. His aging prostate requires him to be within a short dash of a toilet. He finds life a struggle each and every day. He needs a hip replacement.

He was offered a review appointment at a Dublin teaching hospital. The appointment last Thursday was for 2.30pm. Not wanting to keep the doctor waiting he turned up on time and patiently waited in a chair until 6pm when he was finally called in. The senior house officer who saw him was ‘multitasking’, fielding calls from the wards. The patient’s records were strewn on the floor at his feet.

After a cursory examination he advised John that he would have to be ‘worse’ before they could do anything. John politely thanked him for his concern but asked to see the consultant. The consultant offered to refer him to a pain clinic but added that it would take months to get an appointment. John pointed out that, as their records would show, he was already attending a pain clinic and the specialist there told him nothing more could be done and that he needed a new hip. The consultant was unfazed by this news and said he would ‘write to the pain clinic’. They watched him struggle out of the chair and leave the room.

Not one to make a fuss, ever, John took a taxi home. By the time he got home he needed to ‘go straight to bed.

John’s story is typical of the many Irish people who daily endure a third world healthcare system. Ireland’s tax payers, men and women like John forked out for the training of tens of  thousands of doctors who form the backbone of healthcare organisations the world over. But John gave me more. He is grandfather in our family. It pains us deeply to hear that healthcare in that country is now for those with private insurance or those who are prepared to voice their displeasure. Surely it can’t be beyond the pale to organise an outpatient clinic where people are treated with dignity even if, it seems, nothing can be done for them? How do specialists determine who merits the rationed healthcare resources now on offer? John was advised to be very polite to secretaries who have power and influence over their boss’s schedules . The need for reform is compelling. It may not be obvious in ‘official’ data because the whole unpalatable truth is only apparent to those who have not. It doesn’t require research to know that something is very wrong, it simply requires an interest in the experience of those who need healthcare the most.

Picture by Julie Keryesz

My first day as a doctor

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I’ll never forget my first day as a doctor. I donned my freshly laundered white coat, swung my new stethoscope around my neck, clipped the newly acquired Parker pen into my shirt pocket, stuffed a copy of the drug formulary into my coat pocket and made my way to the gynaecology ward of the large Dublin hospital where decades ago on the 1st of August I was to be the new medical intern.

She greeted me with a warm smile as she stood at her desk in the ward office. ‘Sister Eileen Doorly’ it said on her name badge. She must have been in her mid 50s and had the bearing of someone to be respected.

Good morning, doctor.

This was the first time anyone like her had called me doctor and my heart missed a beat.

Me: Good morning, Sister. What can I do for you this morning?

Her: Well, you might want to prescribe an anti emetic for the patients post op doctor.

I hesitated. I knew what the drug was but wasn’t sure about a number of other important details. I hesitated. She watched me closely. Smiling kindly. The formulary was within grasp but I left it in my pocket and chose to ask.

What does the professor like to use post op sister?

Her smile broadened.

That would be stemetil doctor

I unclipped the pen and stood with the nib poised over the first drug kardex.

Me: S..t…..

Her: e..m..e..t..i..l.

Me: Thank you. And what dose does he like to use?

Her: 12.5 mgs i.m. twice a day. 6am and 6pm. The rest, is on your name badge, doctor.

She had a twinkle in her eye. She was teasing me but somehow I could sense that she didn’t mean to be rude. Eileen Doorly spent the following three months teaching me everything I needed to know to get through the most demanding year of my career. She did it willingly, she did it with the deepest respect and she did it with discretion. I am forever grateful to her. I never saw her after that year and because I moved overseas for my specialist training I didn’t have the opportunity to thank her. She also taught me that sometimes it pays to let those who work with you teach you things, to show your vulnerable side and to trust them. I published my first academic paper while working on that ward. It set me up to get a place as one of six to be offered a prestigious training job against stiff competition.

Eileen Doorly inspired that work because in that first week on the ward she explained that my job as an intern was not only to provide basic medical care but to support the catholic Irish women who would be told in the course of their admission that they would be unable to bear children. That experience was critical to my decision to choose to specialise in general practice. In the course of my career I have met a number of people like Eileen Doorly, men and women, older, wiser and more experienced. Always willing to teach, always with the patients best interests at heart. Medicine requires team work, it is a demanding profession in which errors can cost lives. Men and women like Eileen Doorly ensure that patients are not harmed despite the many inexperienced doctors who must participate in healthcare to learn the art.

Picture by Jez

Innovate for quality first

Use of the term ‘quality‘ needs definition before it can be interpreted in any critique of the health service. I propose a definition of a quality as one which can be measured by the extent to which the person with the problem feels that s/he has been seen and heard by a healthcare professional with the requisite expertise. It has resonance with business where if the customer feels that she is not valued she takes her custom elsewhere. However as is sometimes illustrated by some aspiring healthcare providers they understand business but have no clue about medicine. There is a burgeoning of primary care providers, offering something akin to fast food outlets but these are likely to disappoint their clients.

Quality has four benchmarks:

 

There is no ‘quality’ if the patient has no prospect of consulting the person best placed to assist and especially when need is greatest. There are many examples of disastrous outcomes for people who have not been able to access the required expertise in time. In healthcare that may be a surgeon but it could also be a dentist, a physiotherapist, a pharmacist or an allied health practitioner. On that basis it is telling that in Australia access to general practice may be challenging in some communities but so is access to allied health practitioners. For this reason alone these communities have a diminished quality primary care service regardless of any other benchmark.

However ‘access’ alone is a poor proxy measure of quality although it often seems as if the public believes it is the only one that matters. It certainly makes very bold headlines when it fails. On the other hand there is little point in a very accessible service which is not effective. Once the access issue has been addressed the focus shifts to effectiveness. The Royal Australian College of General Practitioners offers a useful list of indicators that might guide a medical practice. Each discipline or organisation is likely to have its own list of ‘quality’ indicators for effective care.

The integration of care providers is a sensitive marker of quality in health care. There are many healthcare issues where a team approach is of critical importance to timely diagnosis or rehabilitation especially when transitioning from another setting. Practitioners in different disciplines rarely work as an effective team not because they don’t wish to, but because team work is inhibited by funding and or organisational  structures. This may be the one area where collaboration could improve quality for modest investment.

Finally, and crucially, continuity of care is a vital component of quality. Simon illustrates the point well. He has been admitted to three different hospitals in the same town over the past three years. He usually finds his way there in an ambulance or via the emergency department. He has two different problems which have been diagnosed as ‘alcoholism and  neurosis’ or ‘epilepsy’ and ‘stroke’ or ‘migraine’. Simon has certainly enjoyed access and on every occasion he has consulted someone who is suitable trained but there has been no integration of providers and the only hope for a good outcome is continuity of care. By any standard, eight CT scans later, he is at risk of iatrogenesis.  After three years he has been told he is fit to drive and not drive in the same month by practitioners with the same specialist qualifications. He has been commenced on antiplatelet medication by one  and advised to discontinue all medications by another. The only hope is that he has the same general practitioner and that continuity of care might be the light in an otherwise dark and it seems radiated tunnel.