Tuesday, 28 June 2011

Corporate Hospitality should carry a health warning..

I have decided to give the NHS a rest for the next few days, it’s all too depressing, and decided to focus on corporate health. One look at a friend who came to visit yesterday and I looked no further for my subject. She was sporting a livid black eye and swollen face and was moving very gingerly, thanks, it transpired to two broken ribs.

‘White water rafting’ was the reply generated by my raised eyebrows. This forty something mother of two had been a guest of an insurance company on a corporate white water rafting day. The raft had capsized, it took her three attempts to get her head back up above water, which in itself must have been petrifying, and en route she received blows to the side and face possibly from a colleague’s foot, from the raft or from a rock. Ouch!

My protestations were met with – ‘yes but I signed a disclaimer’! That’s alright then, all bases covered. This could have been so much worse. My friend, didn’t want to seem too girlie in her male dominated environment, after a quick check from the water sports centre manager (who hopefully at the very least is a first aider) decided to go back into the raft for two more runs. Not because she wanted to, but because she didn’t want to appear weak. If the ribs had been broken, and one decided to ‘pop’ during the next two runs – who knows what could have happened.

Other injuries that I have either witnessed or heard of include;
Broken leg after a wine tasting evening (following a handstand executed in the wine bar – oops)
Frozen shoulder following a corporate archery event
Severe bruising following a ‘human football table’ game

Each of these incidents resulted in extended periods of time off work.

Another corporate favourite, paintballing, can cause serious eye injuries. A spokesman for the London Moorfields Eye Hospital recently stated that they were treating an increasing number of patients with severe paintballing-related eye damage.

The majority of adverse incidents usually involve too much alcohol. I remember that one of my previous employers ran a corporate event every quarter and we always had problems with two colleagues. One who got so absolutely paralytic every time that we had to allocate a minder to keep and eye on him as he had a habit of falling into roads or sleeping in hedgerows in frozen conditions. Funny the first time only. Another colleague was a delightful lady but a very nasty drunk so we had to keep our distance as she became more abusive and vitriolic. All quite amusing but not good in front of clients.

Throw into the mix the 2010 bribery act which defines bribery as ’financial or other advantage offered, promised or given by one person to another, where the intention is to induce or reward someone to perform improperly a relevant function or activity’. In other words, where a reward may influence a buying decision. Some corporate hospitality packages can be highly valuable and valued, such as a box at Royal Ascot or a trip to Paris for a rugby match and these could be perceived as a reward.

So you need to think carefully before you arrange, or accept an invitation, to a corporate hospitality event as it has the potential to become a veritable minefield. Hotbed of corruption, danger zone risking life and limb? Probably not. But all these things need to be considered. Corporate hospitality can still have a useful role to play in business, and often provides a good opportunity to get to know your clients and suppliers better, leading to mutraully advantageous, constructive working relatoinships.

In the meantime, just for the record, I am still a fan of corporate hospitality if it comes my way ….does anyone have any Wimbledon tickets?

Friday, 24 June 2011

NHS Reform – 'cut and paste' politics

For a few weeks I have been avoiding watching the BBC coverage of proceedings in Parliament because the waffle and posturing by the majority of MPs makes me tense. But as the Health and Social Care Bill has been going through recommittal proceedings this week, I felt I should tune in to BBC Parliament, and the weekly political panel show, Question Time, to make sure that I stay on track with the progress (and I use the term loosely) of the Bill.

Recommittal sadly puts me in mind of funerals and the ‘committal stage’ and I must confess that following the political melee of this Bill has a similarly depressing effect on me. Alas, politics is hampering, not facilitating NHS Reform.

The debate in Parliament on Tuesday was to pass a motion for the Bill to be ‘recommitted to a public bill committee for reconsideration’. Approximately 160 amendments are being made to the Bill, incorporating changes to 63 clauses and 6 schedules, a significant rethink on the content of the original Bill.

The debate was meaningless, as this recommittal was fully supported by the coalition so this was a rubber stamping exercise to allow the Bill to progress to Public Committee. Even though there were very few MPs in the House for the discussion, which was limited to one hour, I found the spectacle unusually entertaining.

Andrew Lansley, UK Secretary of State for Health, allowed another Health Minister, Simon Burns to do the talking. Burns rambled on at the outset with the usual political schpeel and was admonished by the Speaker (for overseas readers – the speaker ‘controls’ MPs during parliamentary sessions) for wasting time and not specifying the point of the motion. He may have been trying to use as much of the allocated hour to splurging soundbites to avoid discussion and his performance was petulant, grumpy and defensive. He talked of a ‘bottom up culture of clinical leadership’. I have no idea what that actually means and could only think of proctology!

Burns continued ‘while the pause has finished, we will never stop listening’ … mmm – why don’t I find that reassuring?

John Healey, Labour Health Minister, was much more eloquent and persuasive. Admittedly – it is so much easier to be in opposition when it comes to a gritty issue like the state funded health service, but even so, he spoke with confidence and conviction. The Labour line was that the entire Bill should be reconsidered as changes reviewed out of context do not give a clear picture of how the reforms will ultimately work. He talked about ‘A wasted year of chaos and incompetence’ and the ‘sclerosis of the health service’ and sadly I agree.

John Pugh of the Lib Dems got up to support the amendments but wasn’t convincing and it struck me in a moment of madness how wonderful it would be to have a free vote on NHS Reforms, with no party Whip to bully MPs into agreement. Now that would be an interesting debate

BBC Question Time was equally depressing. What was once a lively panel show with political and topical debate – it is usually now a deadly regurgitation of party political speak and ‘on the fence’ opinions. One consensus view was that the Coalition, rather than impressing the general and political population with their listening skills and flexibility, are constantly weakening their position with a succession of U-turns. These U-turns include privatisation of forests, sentencing policy, defence cuts and university tuition fees. So moving the goal posts on NHS Reform seems like just one more change of heart. Indeed the coalition seemed to have made more U-turns than a motorist with a malfunctioning Sat Nav!

But The NHS is different. Why? For two main reasons Firstly, the vast sums of money involved, year in, year out and secondly because this Bill effects each and every one of us. Even the fabulously rich get taken to an NHS hospital in an emergency. This is just too important to get wrong.

The politics have confused the issue. The Public Bill Committee will now be reviewing only part of the Bill. For instance only the amended clauses involving Monitor, the regulatory body, will be reviewed, out of context of the total responsibilities. Cut and pasted reports rarely work and a ‘cut and paste’ parliamentary Bill should not be the way forward

We are no nearer a real solution to NHS woes. Some units are ‘business as usual’, some GP practices are staffing up for consortia whose remit may now change, some agencies are continuing, with fewer staff, to undertake functions they expected no longer to deliver. The politics go on. The Lb Dems try to take credit for a U-turn, the Tories try to show they are still listening and Labour enjoy something to get their teeth into in opposition.

Meanwhile the NHS lumbers on – a rudderless ship whose crew are doing their level best to keep afloat while the admirals play chess.

Tuesday, 21 June 2011

Response to the NHS Future Forum: A wide range of emotions...

‘The House of Commons will vote on a motion to recommit the Health and Social Care Bill to a public bill committee for further consideration on 21 June 2011.’ This was the helpful missive I received today as a subscriber to UK Parliament updates.

Andrew Lansley, UK Secretary of Sate for Health, will hope that his reformed reforms are back on track, ready to be ushered through parliament towards the House of Lords.

I have now had a chance to review the proposed changes and as usual, am experiencing a wide range of emotions.

Satisfaction: That the government has listened and appreciated the strength of opposition to the content of the original Bill. David Cameron has realised that taking his eye of this particular ball was potentially highly damaging for not only the NHS but for the Coalition too. It is also gratifying to see that the listening exercise appears to have produced a genuine change of direction in emphasis and execution of the Bill.

Encouragement: That some of the key areas of dispute have been addressed. Despite Lansley’s insistence that all-encompassing power should be handed to GPs, there is now an understanding that this is not the view of the majority of stakeholders and indeed is not the choice of many GPs either. Interesting to note that when I first started this blog last year, the original spend to be handed to GPs was £80 billion annually. That quickly but quietly changed to £60 billion and is continuing to shrink. I am delighted to see that ongoing professional development is acknowledged as key. I also agree with the proposed change in the role of Monitor, the regulatory body, with regard to managing competitor activity, ‘protecting and promoting patients’ interests’.

Confusion: That there is still no explanation of how these reforms will actually deliver better, more cost effective care. The challenge the government has tasked the NHS is a reduction in costs, year on year of 4% for the next 4 years. How are these changes going to save money? The staged introduction of Clinical Commissioning groups is a little woolly, ‘Where a group is not ready, the local arms of the NHS Commissioning Board will commission on its behalf’ This begs the question – why not let the local Commissioning Board do the commissioning - full stop?

Concern: How will the damage caused by extended timescales and slow painful death of Primary Care Trusts and Strategic Health Authorities be mitigated? The loss of experience and intellectual property could be massive. An estimated £772 million will be spent on redundancy payments and I have seen first hand that it is the most able and re-employable that are accepting this way out. It is expected that many will be re-employed by the commissioning consortia. Indeed, in Lansley’s proposed changes to the Bill he states that the NHS needs to ‘ ensure that high quality management is valued across the NHS with a commitment to retaining the best talent across the PCTs and SHAs’ Oops! In panicky response to the original timescales, many of these people have headed for the hills, with a nice fat cheque in their back pocket.

Frustration: That this fiasco could have been avoided with more thought and consultation in the first place and major restructure of the NHS was not in the original political manifesto. There is still no evidence that although it is universally agreed that quality and efficiency improvements are essential for the NHS, top-down, bottom-up or middle-out restructure, whichever way you look at it, is not necessary or even desirable to achieve these improvements. Improved culture, refined practices, better management and robust quality assurance could deliver the required results.

And finally….

Hope: That somehow the intelligent and committed clinicians, patient groups, administrators and interested parties will interpret these reforms in an inventive, workable and practical manner to achieve the worthy aims of this troubled piece of legislation.

Monday, 20 June 2011

View from an inpatient bed (3): The one about communication

‘The single biggest problem in communication is the illusion that it has taken place.’
George Bernard Shaw

One of the few things that Andrew Lansley has admitted he got wrong so far is that he failed to communicate properly how the NHS reforms outlined in the Health and Social Care Bill could actually work. The ‘listening exercise’ that led to the planned changes to the reforms has at least allowed for the drafting of this Bill to include two way communication.

Despite all the talk of NHS cuts and lack of resources, which is undoubtedly having a major impact nationally, I received excellent care as an inpatient for a few days a couple of weeks ago. But during my stay the most significant shortage that I experienced was that most precious of commodities – communication.  Communication is quite simply at the heart of everything we do and is probably the single most important tool in healthcare service improvement.

I witnessed shortcomings at every level. Failure of communication between peers, failure ‘up and down’ the medical hierarchy. Failure in communication with patients, relatives and visitors. Everyone working in their own bubble under the illusion that they were communicating effectively.

Nurse to patient: I arrived on the ward just before midnight and in hushed tones a very charming nurse explained to me in the dimly lit bay that there were ‘many forms’ to be completed before I could retire for the night. I completed one questionnaire and he left the ward, soon to return with another. After two fairly basic but faintly ridiculous questionnaires (was I living in wardened accommodation? Could I dress myself – I promise you, dear reader, I am not quite in my dotage yet), he disappeared into the night again and I waited, presuming another form was coming my way. I waited and I waited. Eventually – I got up and went to the nurses station where he was chatting with his colleagues. ‘Can I go to bed now?’ I asked plaintively and he nodded in surprise. Alas, I didn’t have my crystal ball with me that night and how nice it would have been for him to communicate with me that he had finished his questions.

Patient to nurse: Maybe it would be a good idea to explain to patients what to expect from the nursing and healthcare assistant team. The lady in the bed next to me had unfortunately broken both arms so needed help with the most basic of care, which on the whole she received to a high standard. But she didn’t know if she was supposed to press the call button when she wanted to get dressed or undressed or whether she was supposed to wait until someone offered to do it for her. This caused her some concern every morning and evening as she simply didn’t know how she was supposed to communicate with the nursing team.

Nurse to nurse: The handover rounds were appalling – a senior nurse mumbling to the amassed audience, imparting useless information. There clearly hadn’t been an ‘offline’ handover either. The little old lady – I’ll call her Molly-  in the bed opposite me (I was the only one in the bay born before the 2nd World War!) suffered from what I call happy dementia. She had no idea what was going on but was perfectly content in her own little world. She called me Dot for my entire stay and I was happy to comply. It was getting late one evening and Molly wanted to get back into her bed for the night. But she had no nightdress so put her dressing gown over her clothes and clambered in – at which point I toddled off to the nurses station (interfering? Moi?) to ask a nurse to bring a hospital gown and help Molly get ready for bed. The nurse happily complied, but had no idea that Molly was incapable of looking after herself. Surely this should be part of the handover process?

Doctor to nurse: The nurses changing beds one morning spent quite a bit of time complaining about how poorly the doctors communicated with them. They were, of course, breaking the golden rule of any service industry (and let’s face it – healthcare is the ultimate in service delivery). The golden rule? Don’t whinge about or undermine your colleagues, boss or organisation in front of your clients. Yes – the patients are clients. Often fragile, vulnerable clients. I was desperate to tell them that they were just as guilty of poor communication by not voicing their concerns to the doctors in question but as these nurses were in charge of needles and I was the recipient of many such needles during my stay, I felt it was wise to keep quiet.

Nurse to doctor: Still on the subject of doctor/nurse communication – every evening my 6 pm dose of IV medication was late – up to an hour and a half late. When I queried this, a very agitated sister pointed out to me that it was impossible to give a 6pm IV dose to everyone who needed one at 6pm and the doctors shouldn’t write patients up for a 6pm dose. Have you discussed this with the medical teams I asked? I was sure there was a simple solution. Surely this is something you discuss at the MDT meeting? (multidisciplinary team meeting). For months the ward had been struggling to meet a 6pm deadline which clashed with the normal drugs round, supper, dealing with visitors etc, and no-one had raised this issue with the doctors.

General communication skills: Oh how I would love to spend just an hour training the ward staff in communication. For the staff from overseas, I would make sure they knew how to phrase the most basic questions in colloquial English. One doctor caused great confusion by asking one of my fellow inmates where she was before she came into hospital. Of course the patient replied with details of exactly where she was when she had her accident – on the bowling green – (who would have thought that bowls was such a dangerous sport). This became a saga as the questioning continued – where was she staying? Did she live at the bowling green? Was she in a residential home? In the end, the patient finally understood – the question should have been ‘where do you live?’

I would teach the staff how to address patients – if you are doing the ward round – you acknowledge the patient. Whatever you do – do NOT talk about them as thought they are invisible. I would teach listening skills and how to get your point across in a non confrontational way. Communication with peers is even more important than communication with the patient in many cases.

The only way to achieved integrated care is through clear communication. If just one part of the pathway, i.e. the inpatient stay, is fraught with difficulties, you can multiply that manifold when you also consider primary care, community care, therapy teams, and social care.

Maybe the key is to ensure that the regular MDT meetings follow strict guidelines so that all key points are covered. Maybe the new clinical commissioning teams will include clear and measurable communication as part of the required standards. Whatever happens with the reform plans, communication at all levels is a vital part of the service improvement process.

Friday, 17 June 2011

View from an inpatient bed (2): The one about waste

Warning to reader: minutiae alert – apologies, but it’s often the little things that count….

My time was one thing that didn’t go to waste during the three days I spent as an inpatient recently. Not only was I set on the path to recovery, I was able to watch the comings and goings of a hospital trust, still wearing my service improvement hat, but viewing daily routines through the eyes of a patient.

The emergency department appeared very efficient, but I would love to know how many patients were there because they either didn’t have a GP or the out of hours service from their local practice was inadequate. There was a large number of walking wounded, or as we used to call in the trade – ‘bites, bumps and bee stings’. Alas my daughter stopped me from undertaking an instant poll on every new entry as I waited for the doctor.

Regular readers of this blog will know that I’m pathway obsessed and believe that tailored, locally agreed pathways using national evidence-based criteria for best practice will lead to efficient patient services. Which brings me to my first question. I knew I was to be admitted so the routine tests such as a targeted blood screen, blood pressure and temperature were to be expected. But I also had a chest X-ray, which is ‘routine’ according to the radiographer. There may be a very good reason to screen every patient pre-admission (I wasn’t due for surgery) but I would like to understand why this was done. Check for signs of T.B. maybe? Or is it simply because they always have done? Multiply this by the 48,000 inpatients admitted annually to the hospital and the sums start to get interesting.

Although I needed regular intravenous medication, I wasn’t actually unwell (infected ear) and was as in control of my faculties as I’ll ever be, so I was a little frustrated when I was told I must wait for a porter to take me to the ward. 20 minutes later, a cheery chap with a wheelchair turns up, and despite my protestations, insisted that I must be wheeled to my destination. Already institutionalised, I meekly sat on the chair and he wheeled me to the centre of the emergency department when he was called away. So I was left, stranded like a broken-down car in the middle lane of the motorway, smack in everyone’s way. (A highly amused doctor kindly moved me over to the hard shoulder). And when my chauffeur did finally appear I had a very rocky ride to the ward and can safely say that was the only time I actually felt sick during my whole stay! A time wasting exercise which meant that the department nearly missed the admission time target for this particular patient.

And this was the theme throughout my stay. Yes, I had excellent care and wanted for nothing – but how many processes and practices are undertaken simply because they always have been?

A considerable amount of nursing and healthcare assistant time seemed to be spent in ‘handovers’. And not very efficient handovers at that. Every nurse was told about every patient. Surely if they reverted to the old system of allocating a nurse or nurses to a bay of patients there would be far better continuity of care, and less time wasted on handover. And ‘bring back Matrons’ I hear you all cry in unison. Lack of time seemed to be the commodity that nurses complained of most yet if they studied their policies and practices I’m sure that significant savings could be made. The water jugs were changed three times a day – possibly by a volunteer. But I doubt if a volunteer was washing them. Is it really necessary to give a patient 21 different water jugs in a week? They say look after the pennies and the pounds will look after themselves.

Another fine example of wasted resource was the drug round. The nurse undertaking the drug round (which most times took forever because each nurse didn’t seem very confident in handing out the drugs) wore a bright orange plastic apron with ‘Drug round in progress – do not disturb’ emblazoned on the front. Not only did this make the wearer look ridiculous (I’ve only ever seen do not disturb sign on a door not a person), this has to be a waste of money.  The fact that the person doing the drug round is pushing a big trolley full of medicines is a bit of a giveaway without the apron which  was discarded after each round. I calculated that at least 50,000 – yes 50,000 of these aprons would be used in this one hospital annually. (I told you I used my time well…)

This may all seem trivial but multiply these few small examples by 1 million NHS in-patient admissions a month and you can see how small changes can have a big impact,

Talking of time well spent – the volunteers that came to change the beds daily were brilliant. I reckon they took an average of half the time to change one bed compared to two nurses. Possibly because they were happy to come to the hospital for a couple of hours and ‘do their bit’.
This is where Cameron’s Big Society can play a role. Well trained volunteers undertaking menial tasks could save a great deal of trained staff time.

NHS reform shouldn’t be just about cutting staff or - as I’ve quoted before – rearranging deckchairs on the Titanic with complex, and sometimes pointless restructure. Good managers creating robust, sustainable and lean systems of care, both clinical and pastoral could create the efficiency savings needed.

Best clinical practice, supported by well organised daily care and good man management is the most cost effective and efficient way to run an improved NHS.

Tuesday, 14 June 2011

NHS reforms are beginning to feel like a long running TV reality show

It was a classic piece of television and, I suspect pretty much sums up how many of us are feeling about the NHS reforms.

An Orthopaedic surgeon loses his cool with the Cameron/Clegg/Lansley roadshow as they film yet another piece for TV news. The happy looking NHS patient in his bed, pretty wife alongside and the three wise men sitting round the bed like a modern day nativity scene.

In comes the surgeon – shouting at the camera crew who have clearly breached the hygiene regulations so important in keeping infection at bay in a busy ward. The surgeon insists that the circus leaves town and order is restored to his kingdom. Quite right too. It made for great viewing but also brings home the reality of this long running saga and was, for me was the single most significant moment of the day.

The news channels have deluged us with reports of the government response to the NHS Future Forum and I have absorbed as much as I can. My first reaction on reading the summary of the proposed changes to the reforms was to feel encouraged that the ‘nay-sayers’ were beginning to win the day and the coalition really had listened.

Overall accountability for health to rest with Ministers, nurses and secondary care doctors to be on the commissioning teams, Monitor to represent patients needs and choice. More support for integrated care and a relaxation of the challenging timescales for reform. It all sounds quite sensible.

But still so much is unclear and it all feels a bit unworkable and unreal. Dr Jennifer Dixon from the Nuffield Trust gave a very intelligent summary of the current situation. She pointed out that the main challenge facing the NHS was efficiency savings. And she is right. Any major restructure costs money and uncertainty is the enemy of efficiency.

And so the long running saga continues – it feels a little bit like it’s getting out of hand. Every time I see Cameron, Clegg and Lansley I can’t help thinking of the phrase ‘how many men does it take to change a light bulb’

Or maybe it should be ‘how many men does it take to dig a hole?’.  We are still in that hole but one character in today’s episode showed that he knows exactly what he wants. Yes he was a stereotypical surgeon, a ‘Prima Donna’ in his bowtie.

But for me, at least, he’s today’s hero.

NHS: When local isn’t always best

I seem to be turning into a bit of a one woman mystery shopping organisation for the NHS. This time the on-call ENT service was put to the test.

My ear condition flared up yesterday afternoon and I needed to see a specialist - pronto. As always, my fantastic GP saw me immediately after I described the symptoms on the phone. I have decided that I must have been very good when I was little and have been rewarded by the gods with a GP practice with excellent access and quick response times. I am fully aware that this isn’t the same throughout the UK.

Then it started to get tricky. One of the problems with the current state of flux in the NHS is that it’s constantly changing. So practitioners at all stages of the patient pathway aren’t actually clear on how to access some services. My GP phoned four (yes four) local NHS Trusts before he found one that provided an on-call ENT service. And we’re not talking midnight here, this was 2 pm.

My first reaction was – how awful that someone who is supposed to be at the hub of primary care services hasn’t been informed of each change in those services.  My next reaction was annoyance that I would have to travel half an hour to see a specialist, when there are at least five hospitals geographically nearer. This is the stuff of great political fuel – ‘patient drives past two hospitals before she can find the treatment she needs’.

But fast forward half an hour (and let’s face it –what’s half an hour if it means you’re going to get better quicker?) I was in front of an ENT specialist. And the clue is in the name - specialist. He immediately assessed my poor ear in the emergency department and then walked with me to the specialist ENT department where he undertook a specialist procedure requiring specialist skills and specialist equipment.

It would not be cost effective for this service to be available in every hospital.

So, as the NHS reforms are re-formed (more of that later when I’ve had a chance to digest all reports) there are two vital areas of communication that must be addressed.

Patients must be informed of the reasons of moving treatments to specialist centres. They need to understand the rationale. And GP’s – commissioning or not – need to understand how to access care for their patients. Which brings me to a final point. I believe that a Communications Director in each NHS Hospital Trust will be almost as important as the Chief Executive.

Yes – local isn’t always best – but everyone associated with delivering and receiving care need to understand what is available, where and why.

Sunday, 12 June 2011

View from an inpatient bed (1): The one about accountability

This could be titled – the one about the tissue. It was a tissue, spattered with tiny spots of blood lying on the middle of the ward floor that caught my attention at 6am on the first of my three days in hospital.

The hospital ward appeared spotless – and, as I found out later, was cleaned thoroughly at around 10am every day. But that wasn’t the point.  The footfall in the four-bedded bay was multitudinous for the first few hours of the day. A nurse changing my IV, another doing the drug round. The lady who brought tea at 6.30 and breakfast at 8. A team of nurses on their ‘changeover round’ at around 8. The man who brought the clean water jugs. A surgeon and anaesthetist visiting a pre-op patient. The healthcare assistant who did the observations round at 9. The volunteers who changed the bed linen.

Each and every one of these individuals either failed to notice or chose to ignore the tissue. Nit picking? I don’t think so. It made the bay look untidy and posed a potential health hazard. So why did no-one pick the flipping tissue up and put it in the clinical waste bin?

Ownership and accountability. Who actually ‘owned’ the bay? Who was accountable for each patient? Each operative in this apparently efficiently run unit were very clear of their roles and responsibilities. And this is the problem in compartmentalising care, even at this level of minutiae.

My daughter undertook an excellent post graduate training programme in bar management with a large hospitality chain. One of the first things she was taught was responsibility for everything that happened in the bar. When she moved into management she encouraged a similar approach with her staff. Torn menus, dirty tables, rubbish, even toilet roll in the customer bathrooms. Each member of staff was encouraged to take personal responsibility for the customer environment. Likewise with my pharmacy training – university and post graduate, it was constantly drummed into us that we were ultimately responsible for everything we dispensed.

Another point only struck me after my discharge. During my stay I was ‘touched’ (in many cases literally) by at least 50 staff, clinical and non-clinical, night and day. I should be very appreciative of this intense level of interaction and I am. But although each task necessary for my wellbeing and recovery was undertaken with kindness and efficiency, the cause of my admission (ear) was only actually looked at by the consultant on his daily ward round. It would have been nice if the people administering the drugs and my daily care showed some level of interest in whether the treatment was working.

And not once did someone ask me ‘how are you feeling today?’

In my previous blog I talked about the benefit of a time and motion study, to look at the way care is delivered and find efficiencies. This should go hand in hand with training on accountability. Ownership of the environment (whether it’s a GP practice, health centre, or hospital department), ownership of the patient and a holistic approach to their treatment, both medical and pastoral.

And the tissue? My control freakery took over and after 3 hours of observation, I cracked and picked it up myself.

Friday, 10 June 2011

View from the front line. Finchers takes research to the next level...

It wasn’t in the masterplan, but I experienced a good chunk of the NHS patient pathway this week as I was admitted to an NHS hospital via an out of hours GP service and Accident and Emergency Department (A&E). A testimony to this obsession for writing about healthcare was clearly apparent as my close friends and family, without exception, all said – ‘you’ll get some great material for your blog’ when they heard of my incarceration.

I shall spare you the gory details but I am now home, the walking wounded, not necessarily richer, but definitely not poorer for the experience.

there is indeed sumptuous fodder for a healthcare blogger as an NHS inpatient. None of it particularly shocking, mainly reaffirming of my current viewpoint actually. Today’s commentary is a summary of all that was good about my experience and I shall add some postings over the next few days on areas where ‘could do better’ would be the score on an end of term report. These areas (probably no surprises) will include Communication, Accountability, Time Management and Waste.

For the past two years all my time spent in hospitals has been in an official capacity, skirting around the edges of the actual patient experience. This time as an inpatient, my first since becoming a blogger, was particularly fascinating as I tried to view every nuance of the service and the people who provide it from an independent, detail-thirsty and hopefully objective view-point.

My whole experience was, on the whole, highly user friendly and possibly life-saving. I received timely, appropriate, and in the main, well delivered care throughout.

I know that I am lucky to live in an affluent area with good GP access, who happen to have an excellent out of hours service. Without going into too much detail, my GP himself ended up seeing me out of hours and immediately phoned the hospital who advised that I should be admitted.

Time from my phone call to out of hours service to seeing GP: 20 minutes
Time from GP assessment to referral: I minute

Note to Mr Lansley: (UK secretary for state for health). This is what GPs do best. They know a patient’s history, they provide front line advice and triage and they refer if appropriate.

Within an hour of arriving at the A & E department, I had been thoroughly investigated, diagnosed, treatment started and the search for a bed had begun. The clock started ticking and I was fascinated as staff made frantic phones calls and juggled names on boards, reminiscent of the archived news reports of naval ships being manoeuvred across a board in the planning rooms in bunkers under Whitehall during the Second World War. And hey presto – with just 3 minutes to spare, I was whisked to my duly allocated ward, with the A & E target intact. Money saved for the Hospital Trust and a patient happy to be admitted without too much delay. (The target is: decision for admission to patient reaching hospital bed – 4 hours)

Time from admission decision to reaching allocated hospital bed: 3 hours 57 minutes.

Note to Mr Lansley Targets work. I would probably have had to wait many more hours for a bed. The four hour window was constantly on the A & E staff’s mind

The four-bedded bay on the ward was well equipped, light and airy. It was spotlessly clean, not particularly well run, but care was delivered as needed. I was surprised not to see a pharmacist, especially as I was a medical, not surgical patient. But I was cared for and assessed by at least two consultants a day, several junior doctors, many nurses and an army of healthcare assistants. I shall talk more of this in another blog as it appeared to be a case of many hands not making light work…

Note to Mr Lansley: You are absolutely right, efficiencies need to be made in Hospitals. But the existing core services and infrastructure in many, many cases are very good. Restructure, reform and reconfiguration is a drastic way to provide improvements that could be achieved through sensible pathway mapping, realistic and unambiguous service delivery targets and minimum capital equipment requirements. Improved recruitment processes, communications training and ongoing professional development are badly needed. And most important of all, a good old fashioned time and motion exercise to assess how manpower is being used would be money much better spent than changing the commissioning process.

I was given over £1000 ($1600) worth of medication during my three day stay. My take home drugs would have cost around £200 ($320). The food and facilities were excellent. A wide choice of menus, regular tea and coffee rounds, clean sheets and towels every day, fresh water delivered to your bedside twice daily – pretty much like a good basic hotel. If I hadn’t been treated promptly, this blog would have told a very different story, with far reaching effects for my future health. This particular patient is due to make a full recovery.

Cost to patient for all these services including medical consultations and nursing care, x-rays and blood tests, medication, accommodation and food: £0.00

Note to Mr Lansley:  Bless the NHS!

Monday, 6 June 2011

If I was David Cameron's speech writer....

The Daily Telegraph today outlined the five pledges to the NHS that David Cameron will include in a keynote speech tomorrow. In summary they are:

·         Keep waiting lists low
·         Maintain spending
·         Not to privatise
·         Keep care integrated
·         Remain committed to the ‘National’ part of the health service

I’m not a spin doctor, so don’t really understand why you would leak the contents of a speech beforehand as it gives people like me plenty of time to identify weaknesses and must have some effect in reducing the impact of the message.

These pledges do beg some questions.

At least we don’t need to ask ‘why?’ No-one can dispute the need to reduce costs and improve service. There is not one organisation in the land that would not aspire to such a worthy aim (apart from a well-known mobile telephone provider who severely tested my good nature recently and seem to be bent on rubbish service with confusing cost schedules.)

The more important question is ‘How?’

Those of us who are now obsessed with the health reforms, and I suspect, many more besides, are pretty tired of the what and why – we want to know ‘how’.

If I was Cameron’s speech writer for the day this is how my advice would go..

Firstly, Dave, don’t repeat any of the old soundbites that your health secretary, Andrew Lansley has been splurging out. Not good. We know he means well but we need concrete facts and action plans now. I know that I don’t have the answers, but my job is to provide commentary and maybe the odd suggestion so it really is down to you and your advisers to get this right.

I would suggest that you stick to these pledges, with some tweaking, and craft your speech around the following:

‘Sorry’ – Our intentions are good, reform is needed, but we didn’t think it through properly and we acted hastily. We will take guidance from Steven Dorrell’s select committee and the results of the Futures Forum. Yes we have ‘paused, listened, reflected’ and here are our improvements.

‘Why’ – A very brief summary of the challenges facing any state provider or healthcare.

‘What’ The five pledges listed above are good – stick with them, but they need qualifying with …

Keep waiting lists low: Unpopular as they may be in some quarters – targets work, I’ve seen it first hand at many hospitals. In fact ‘targets’ are the same as ‘outcomes’ really. If outcomes are measured and benchmarked against reimbursement they become targets. The other way to keep waiting lists low is through all the other measures in the following pledges. Maybe ‘keep waiting lists low’ should be supported with ‘provide efficient services in primary, secondary and tertiary care, through effective management, ongoing training and robust cost and quality controls’

Maintain spending: My father used an expression – ‘good money after bad’ when someone spend excess funds on repairing something beyond help – like replacing the engine on an old banger when the chassis was falling apart. I think ‘maintain investment, ensuring value for money’ would be more acceptable. This value for money could be achieved through effective commissioning, using existing expertise. (why re-invent the wheel?) Standards should be agreed centrally and applied locally.

Not to privatise: perhaps could be better stated ‘subcontract suitable services based on local need, quality and cost effective delivery’. The private sector can still play a crucial role in supplementing and supporting the NHS.

Keep care integrated: Again – a worthy pledge but care isn’t integrated currently. It isn’t even integrated within individual units let alone across the entire patient pathway (My stepdaughter being given breakfast in hospital this morning only to be visited ten minutes later by an anaesthetist saying she was first on the list today for major orthopaedic surgery. Not having had breakfast she wasn’t) I digress. How about ‘agree integrated pathways to ensure that patients receive the best possible care’. This can achieved by training and communications. In fact let’s add another rider to this pledge ‘improve communications across each patient pathway’

‘Remain committed to the National Part of the Health Service’ Oops, a bit of a soundbite going on there but it is reassuring to hear you say this.

So Dave, here is your crib sheet for your five pledges for the NHS – reworked:

1.  Keep waiting lists low by providing efficient services in primary, secondary and   
    tertiary care through effective management, ongoing training and robust cost
    and quality controls.
2.  Maintain investment, ensuring good value for money
3.  Subcontract suitable services based in local need, quality and cost effective
4. Agree integrated pathways to ensure that patients receive the best possible   
    care and improve communications across each patient pathway.
5. Commit to offer world class healthcare, free at the point of delivery and  
    maintain the best traditions of the NHS while seeking improvement in quality
    and outcomes.

Sunday, 5 June 2011

Keep It Simple, Stupid

Many of you will be familiar with the KISS principle (Keep It Simple, Stupid), and often the best solutions in health and wellbeing have their roots in this principle.

It has been reported today that the National Institute for Clinical Excellence (NICE) is drafting guidelines for fast food outlets to reduce their portion size for chips – a national favourite in the UK. It’s easy for your first reaction to be ‘doh – of course smaller portions are better’. You may also wonder why the watchdog created to pass judgement on the efficacy and cost effectiveness of treatment regimes should bother itself with something so basic.

But when you consider that the annual cost of obesity related health issues in the UK is £4.2 billion suddenly any measure is worth considering.

Likewise in the US, a staggering estimated 33% of children born in the last decade will develop diabetes, the majority directly linked to over-eating.

I have just returned from a week of brunches, snacks and dinners in New York and it is probably more by luck than judgment that I haven’t put on any weight. Anyone who has crossed the Atlantic knows that American portions are enormous (except in the most expensive restaurants of course). The delicious blueberry pancakes came not in twos but fours, with a side garnish of maple syrup. Individual omelettes can be made with a choice of 2 to 6 eggs! It’s hardly surprising, but nonetheless shocking that an estimated 50 percent of food produced for home consumption is actually thrown away in the US.(University of Arizona)

Even more upsetting, the waste and Resources Action Programme found that salad, fruit and bread were most commonly wasted and 60% of all dumped food was untouched. But we have no reason to be smug in the UK as our obesity epidemic continues apace.

Anyone who has the propensity to overweight does not usually suffer from lack of knowledge. Most people in the so called civilised Western World know that a healthy balanced diet consists of limited quantities of a mix of the main food groups. Even if their education doesn’t stretch that far – they know that large amounts of fatty and sweet foods make you fat. The one thing most of these people have in common is a lack of a stop button. It’s so easy to just keep eating if a delicious, probably ‘sinful’ food is still on your plate. Even low fat foods in large quantities become high fat by sheer volume.

So back to KISS. Initiatives in the UK have so far had little effect on obesity among the population. The ‘food police’ go through children’s lunchboxes at school to remove offending items such a crisps. But the point is – a small packet of crisps at lunchtime, accompanied by a sandwich with a healthy filling and maybe some small quantity of something sweet for a child of healthy weight is absolutely fine. It’s the quantity of these foods that counts.

If providing smaller portions can reach a group of potentially obese people who like to eat fast, fatty food in large quantities, then this has got to be worth a try.

Education, incentives and brow-beating don’t appear to work so hitting the problem at source could have some effect.

And while we’re at it – wouldn't it be great if any re-writing of the Health and Social Care Bill keeps the KISS principle at it’s heart too.

I live in hope.

Thursday, 2 June 2011

NHS Reforms - Good surgery cures, bad surgery kills

In the few weeks since the NHS Future Forum was launched (you remember. listen, pause, reflect, improve), Andrew Lansley has been strangely quiet.

Maybe the UK Health Secretary has been listening, pausing, reflecting and improving after all, I wondered? Maybe he’s being sidelined? However one views the planned NHS Reforms, no-one can deny that the way they have been positioned has been potentially very damaging for the Coalition. Maybe he’ll be sacked? None of the above. Instead, he has his head above the parapet, leaping out of his bunker with renewed vigour but same ammunition I’m afraid.

Writing in the Daily Telegraph today under the headline ‘Why the health service needs surgery’ Lansley writes with good sense about the challenges facing any state funded health system in this age of increased life expectancy, expensive innovations in treatment and costly drugs.

He is spot on – the NHS does need surgery. But we need good surgery not bad surgery. A bit like a plumber removing your appendix with a combine harvester – the wrong treatment for our ailing healthcare system by badly qualified operatives will do more harm than good.

In the article, Lansley quotes facts and figures regarding cost projections. Of course we need to review the fundamental way that care is delivered, quality maintained and performance measured. But I, and many others still fail to understand how the reforms laid out in the Health and Social Care Bill will achieve the cost reductions and service improvements needed.

Yet again, Lansley fails to explain how GP’s undertaking a commissioning function will save money and improve services. Millions of pounds have been paid in redundancy payments to staff from Primary Care Trusts who are already being re-employed by Consortia to fill their commissioning skills gap.

Will the extra layer of management removed by the Bill re-appear in a different guise elsewhere? Where are the safeguards against this? How will empowering patients (a worthy and indisputable goal) reduce costs? For true choice to be offered, there has to be a surplus in delivery options – simple fact. I agree that better outcomes should be cost effective – but where is the proof that any of these reforms will improve outcomes? Targets improve outcomes. Minimum performance standards improve outcomes. Innovation and ongoing training and continuous professional development improve outcomes.

I truly hope that the listen, pause, reflect and improve initiative allows for all of the above. Alas, Mr Lansley is still failing to convince me.

Surgery to fix the NHS by all means, but surgery based on experience, expertise, research, modelling and informed input.