Referred pain in the care system (or you do your job and I’ll do mine) by Professor Tony Beddow

Introduction by Marcus Longley, Director of WIHSC and Professor of Applied Health Policy

The third in our 20:20 series of blogs for WIHSC’s 20th anniversary is written by Tony Beddow, Visiting Professor of the University, and long-term friend of the Welsh NHS.  In characteristically evocative style, Tony takes us to the heart of the current crisis facing health and social care, and urges us to address causes, not symptoms.


Referred pain in the care system (or you do your job and I’ll do mine)

The notion of referred pain, where the symptoms of a health problem manifest themselves in a part of the body that is not itself the cause of the suffering, is well known. The care system increasingly suffers the organisational equivalent but those managing it – unlike most doctors attending on patients – seem incapable of adequate diagnosis and effective treatment.

The author once worked with a “radical” surgeon of whom it was said that he never made a three inch incision if a two foot one was possible. One only sought his skills when all else had failed.

The care system has too much referred pain within it. Worse, politicians and managers continue to be distracted by where the pain appears, rather than attending to the root causes. A radical approach to treatment is called for.

A few examples will suffice.

The ambulance service regularly fails to meet its performance targets. (unmanaged) demands have risen. Front line vehicles, languishing outside A&E because that department is overflowing are pressed into service as overflow treatment bays. WAST performance targets do not reflect that assumed role. Neither are resources made good to ensure it still reaches the ill and injured in time.

A&E departments are overflowing partly because they never close and are the easy recipients of people who do not require its high powered skills and partly because they struggle to admit diagnosed patients to appropriate wards, or divert them elsewhere.

Wards are full, partly because of rising demand, but also because we have been slow to re-engineer the total care system. We do not provide a complementary 24 hour emergency social care system and primary care is not appropriately keyed into the total care system when care deemed urgent  by the public is sought.

What to do? We could follow the buccaneering approach of my surgeon friend and deliberately expose where the pain in the system is in order to fix it.

For example:

  • Ambulances arriving at A&E would handover and leave.
  • A&E departments would only treat those needing its skills and would move diagnosed patient onto wards if a stay was needed, or would divert them to a 24 hour community based care centre that would take over their care.
  • Wards would immediately move patients no longer needing their skills to settings and agencies better placed, or legally required, to meet their needs

The last change probably requires home adaptations and home care packages to be managed differently, and for residential/nursing home placements to be more available. In short, a round-the-clock social care service designed to “take the pain” could be one result of meeting care needs in a more timely and appropriate way.

Re-designing the care system as a whole to ensure that people rarely languish in the wrong bit of it would flow from knowing where the pain really is.

The sooner we reach a stage where the pain in the system is traced to its proper source – and then addressed – the better.

Professor Tony Beddow                    

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