As Bahraini medics are jailed – we must appreciate our freedom to practice our craft.

I am sure that it’s not only those associated with medicine who are shocked and saddened by the jail sentences handed to twenty medics who treated activists during recent unrest in Bahrain. Jail terms will vary between 5 and 15 years, simply for treating the wounded.

I was particularly moved by a doctor interviewed recently on t.v. – a beautiful young woman, accused of fabricated charges by a military court with political motivation. She was terrified that she will be separated from her young son, and dreaded that the authorities would be coming to take her away soon.

It is inconceivable for those of us cosseted in our open society that we should face such draconian punishments for doing what we have been trained to do – to save lives, protect individuals’ health and wellbeing and treat the sick.

I trust that the international outcry, including intervention by Amnesty International and the involvement of the UK and US governments will prove effective in righting this wrong.

I have written before about how much we take our state funded health provision for granted. Perhaps we are also a little complacent about the relative freedom we have to practice our craft. Doctors, nurses, therapists and even managers. Yes, we need to find ways to control costs and improve quality and yes – as medical advances continue, there will never be enough money to offer perfect care to every patient. But as we bitch and bicker about NHS Reform, budget cuts and transfer of power, we should spare a thought for our colleagues, not just in Bahrain but in hotspots across the globe who literally put their lives on the line to help others.

Never has the Hippocratic oath, penned nearly 2500 years ago, been more appropriate:

'I will use my power to help the sick to the best of my ability and judgement;I will abstain from harming or wronging any man by it'.

Anyone associated with healthcare should support the campaign to free these doctors.

Name and shame or name and praise – badges must be worn by hospital staff.

The UK Newspapers seem to be concentrating on Nursing standards this week. Camilla Cavendish in the Times bravely states that she ‘lay on a ward where most of the nurses regarded it as an imposition to ask them for help’ and she goes on to say ‘dedicated nurses look exasperated at having to work alongside ones whose ability to care extends only to caring about when their shift ends.’

Minette Marrin is equally blunt in the Sunday Times today reporting ‘there have been enough scandals to prove the point that disgracefully bad nursing is widespread’

Both articles agree that varying standards of care are a major concern and lay the blame at two doors. One – the type of training for nurses, introduced nearly two decades ago, ‘intellectualising’ the content and focus. And two – the increasing use of healthcare assistants who are usually unqualified, poorly trained and unregulated.

I wouldn’t argue with either of these points and refer to my blog of 15^th February entitled ‘Can you teach someone to care?’ I have sympathy with the dilemma currently facing the nursing profession. Increasing sophistication of technology and treatment regimes mean that nurses need a wide range of specialist knowledge. But this is no excuse not to care.

Peter Carter, General Secretary of the Royal College of Nursing has said that patients’ relatives should take more responsibility for patient’s care. Patients tend to be split into two camps. Those with healthy, compos mentis relatives who do take responsibility for their care, often in spite of, rather than in association with, the nurses. The other group of patients are the elderly and vulnerable who may have no relatives nearby.

I do agree with the sentiments behind Peter Carter’s comments – joint personal care plans between relatives and nursing staff is a good idea but it’s not always going to be possible or appropriate.

When I was an inpatient recently I was in a four bedded unit with one 90 year old lady who had broken her hip, another elderly lady who had broken both arms and one who was completely away with the fairies. None of these ladies had relatives who lived nearby. Luckily as I was the walking wounded I happily took responsibility to ensure that their day to day needs were catered for – fetching things – holding cups and finding a nurse when needed.

And this brings me to my plea. ‘Finding a nurse’ was tricky – not because there weren’t any around but because I couldn’t tell who was a nurse, who was a ward clerk, who was a healthcare assistant, porter, cleaner or whatever. There was no standard uniform and NO BADGES.

In my role as a change leader, I know that it is so often the smallest changes that can make a huge difference.

Yes we need to get back to basics and look at nurses’ and healthcare assistants’ training, caring attitude, roles and responsibilities. Yes we must support the great nurses who do a fantastic job and censure the lazy or mean (as in any profession) In the meantime, every person employed in a hospital should wear a badge stating simply their name and their job title. And this must include doctors.

There are so many good reasons for this. I have no doubt that it is far easier to do a sloppy job if you are anonymous, but the flip side is that good work can be recognised in named individuals. I wonder how much time is wasted every day in hospitals as patients and visitors struggle to find the right person to ask for advice, guidance or help?

The NHS is a service industry. It’s success or failure rests with the individuals who are tasked with providing technical, medical, practical, personal or emotional care.

If anyone is dealing with mine or my loved ones’ needs in the healthcare environment – I want to know who the hell they are.

Clinical Commissioning Groups – reality is beginning to hit home..

Interesting. A survey of half the clinical commissioning groups has noted concerns among the GP leaders regarding budget pressures, the viability of smaller groups and the inheritance of debt.

The NHS Alliance and National Association of Primary Care jointly undertook this survey, following their coming together to represent CCG’s (formerly known as GP Consortia in the first draft of the Health and Social Care Bill)

Dr Michael Dixon, Chair of the NHS Alliance is finally demonstrating some insight that many commentators have been stressing for months. Apparently grudgingly accepting that boards should now include clinicians other than GPs, he acknowledges that ‘CCGs need to reach critical mass’ to mitigate audit expense. Dixon goes on to state ‘There’s a risk of recreating the old system of 150 Primary Care Trusts’  

Taraah !!

This is what we have been saying all along – CCGs will become PCTs by another name. And how much time, money, heartache, redundancy and service disruption will have happened along the way I wonder?

Dixon is not only concerned about the possibility of inheriting debt from PCTs. He also says ‘My GP leaders don’t want to be in the position of decommissioning services’.

This is the same Michael Dixon who, in bullish mood at the NHS Future Forum back in May said ‘GP’s don’t want to be managed – we want to be seduced’

Well Dr Dixon – time to face reality. With power comes responsibility, with change comes responsibility, with relationships (following seduction or not) come responsibility.  The NHS is tasked to produce a 4% efficiency gain year on year for 4 years. Fit for purpose commissioning means looking at treatment regimes, clinical outcomes and service improvements to deliver high quality, cost effective care. This may involve decommissioning of some services to make way for better systems. A good example of this would be the new oral anticoagulant drugs expected to replace warfarin for selected patients. If warfarin is prescribed less, then the ongoing monitoring of this drug, often involving weekly blood tests and dosage adjustment, will be reduced. Some services within specialist centres currently providing this analysis may be decommissioned. The appropriate body to make such a pathway decision would, of course, be the CCGs

Like a naïve new parents with misty eyes looking forward to their little bundles of joy, coming down to earth with the reality of dirty nappies and the challenges of discipline – GP Leaders of CCGs have a tough job ahead.

There are big bucks to be spent – and big bucks to be saved. There are stakeholders to be appeased and voices to be heard. There are pathways to be considered and local needs acknowledged. All this alongside the day to day priorities of providing tip top primary care to their patients.

Little wonder that, according to a recent survey by the British Medical Association more than half of GPs are expected to retire over the next two years.

Who could blame them?

The NHS is too precious to be a political pawn.

A vote at the Liberal Democrats conference this weekend failed to reach the threshold to allow further debate the Health and Social Care Bill. 235 delegates voted for an emergency debate on the NHS shake-up but 183 were not in favour of regurgitating old arguments. I have sympathy for both sets of voters. As so many commentators, (some far more eloquent and influential than moi) continue to state – Andrew Lansley’s NHS Reform bill is badly thought out and poorly explained and promoted. But again as I, and many more have stated – enough already.

Like a lover who has been dumped – how many times can you go back to he/she who has rejected you and beg for a second, third or fourth chance? Some dignity please!

Like it or not - this Bill has now passed through the House of Commons. That ship has sailed. The debate in the House of Lords will be interesting but even if the Bill faces some more serious hiccups – the momentum for these changes is already underway. The NHS continues to feel like a ping pong ball, having an uncomfortable ride as it is bashed back and forth across the political table.

Speaking to a senior NHS manager the other day – I heard the most sensible suggestion for a way forward. He felt that the Bill should be allowed to go through as it is – too much time has been wasted already – and NHS executives should just run their region adopting their own interpretation of the Bill. As long as high quality local services are provided in a cost effective way,and Monitor or any other regulatory body is happy with outcomes – then does the political finite detail matter? A tempting concept.

Maybe I am a little naïve – but I have a simple plea to all ‘stakeholders’ (a favourite NHS word). It really is time to leave politics out of this – let’s just get on with keeping the best of the NHS and easing out the worst at the frontline - the corridors of hospitals and care centres – not the corridors of political power.

A quick guide to clinical pathway mapping

Anyone associated with healthcare will be aware of the desirability of integrated pathways - joined up systems linking primary secondary, tertiary and community care. Accurate pathway mapping is a vital component for service improvement planning, patient safety enhancement and resource allocation. This will also be a key element for consideration by clinical commissioning groups and I hope that these groups will ensure that they either buy in this expertise or acquire it in house.

Mapping doesn’t need to be complicated and the success of any mapping exercise is gaining the consensus of all key stakeholders when agreeing best practice and operational methods and standards. As a delegate at one of my training programmes said ‘it’s a flow chart!’ Yes – it’s a flow chart – a carefully designed flow chart mapping crucial information.

Here is a quick summary on pathway design which may assist you when planning training and mapping exercises.

Definitions:

A clinical pathway map is a visual tool to help analyse, communicate, discuss and document clinical and care processes.

Macro map: The simplest, high level overview of how a process works.

Mini map:  A description of how a process works, giving more detail than a

macro level but avoiding micro detail, often focussing on a specific part of the macro plan. Every step within this map will represent a specific activity.

Micro map: This is an in depth analysis of the process in question, with every step representing an individual task

Uses of pathway maps in healthcare:

·         As a quality and service improvement tool (recommended by the NHS Institute for      
       Innovation and Improvement)

·         To map the patient journey and service processes

·         To assess clinical decision making

·         To capture detail along a pathway and identify problem areas

·         To assist with training and clarify complicated systems

·         To aid resource planning

·         As a vehicle for clinical discussion and service planning

·         As a risk analysis tool

·         To identify audit and measurement points

·         To identify service gaps and training needs

·         To list cost points

Considerations when planning a process mapping exercise:

·         Is this a paper exercise or do you need a process mapping event?

·         Whichever method you use, allow brainstorming time.

·         If you plan an event, invite all interested stakeholders

·         For any mapping event, a strong, independent and knowledgeable facilitator is essential 
      to ensure that you stay on track and everyone gets a chance to have their say.

·         Remember that many attendees may never have been involved with a mapping exercise
      so a training element to start the event is helpful.

·         Define the process you are mapping

·         Define the objective of creating the map – what are you hoping to learn or achieve?

·         Define start and end points (remember there can be more than one of each)

·         Agree the boundaries – what will be included, what will be excluded

·         Agree the level of detail you wish to map (ie. Macro, mini, micro)

·         Clarify whether a pathway is ‘as is’ or ‘as should be’ - do you need to map both scenarios?

·         Agree the way forward.

·         Try to produce clear and visually pleasing maps after the mapping exercise

In a perfect world:

Everyone associated with healthcare would understand the value of clinical pathway mapping and regularly revisit their systems to assess best practice and continue to improve services and efficiency.

Do ‘women only’ business groups do more harm than good?

There is a discussion thread on Linkedin at the moment with the title: Please join us, I will be talking to the IOD (Institute of Directors) about this issue, we have set up a new group called Women in Business UK, our aim is to actively promote more balanced boards. The leader of this discussion goes on to say – ‘primarily our aim is to get more women on boards’.

As one could predict, the comments that follow this statement are as diverse as they are irritating and entertaining. Interestingly – it’s not just the men who are less than supportive of this aim. The first comment is, in my opinion, right on the money.  ‘I think it’s demeaning to women to suggest firstly that they will not get on a board because they are female and secondly that they should be there irrespective of ability’ Hear hear!

Can you imagine a group called Men in Business with the aim of ‘making sure the guys get the top jobs’! I have written before about chauvinism in the workplace and of course gender differences can create challenges. But men face their difficulties in the office too. To suggest that women are the weaker sex when it comes to work is outdated and unhelpful. The motherhood thing further complicates the issue. Yes, it can be tricky juggling childcare with a career, but more men are hands-on fathers these days. However, until men can actually give birth – women will still tend to bear the brunt of this responsibility, with the inherent limitations this can place on promotion prospects. Despite this, women not only succeed, they excel, not because they are female, but because they are best for the job.

It’s four centuries since Shakespeare’s Hamlet announced ‘Frailty thy name is woman’. We’ve come a long way since then and I suggest that much of this evolution is down to ability and fortitude, not special concessions.

The charismatic leader of the International Monetary Fund, Christine Lagrande infuriated me with her bid for presidency when she pitched ‘ ….if I’m elected I’ll bring my expertise as a lawyer, a minister, a manager and a woman’ (Wooooman carries even more emphasis if you read it with a strong, sexy French accent). Lagrande is no doubt a worthy incumbent of this top job - intelligent, courageous, financially and linguistically highly competent – so why did she have to state the obvious?

When I first set up my consultancy I went along to a woman’s networking event where I met some interesting and charming businesswomen. But I soon recognised (and I risk upsetting some of the sisterhood with this) that there was a hierarchy within this particular branch that was both exclusive and bitchy. I realised that I really don’t care if I do business with men or women, as long as they are supportive, fair and professional.

I do think there is merit in watching out for each other if you are in a male dominated environment – it’s nice to have another woman to keep you company. Likewise with a predominantly female event, I’m sure the men are tempted to stick together. And I do agree with Madeleine Albright (former US Secretary of State) when she said ‘There is a special place in hell for women who do not help other women’. But that’s more about playing nice than creating an uneven playing field.

So I will not be joining the ‘Women in business’ group. I wish them well but prefer to reach giddy heights on merit rather than thanks to an unfair leg up (so to speak).  In the meantime, I hope to continue to enjoy good working relationships with both men and women and as Christine Lagrande should have said (again with a strong French accent please) … ‘vive la difference’!

What next for the NHS? Oh for a magic pill.

Regular readers of this blog will know that I occasionally list the good, the bad and the ugly, when taking a snapshot of the NHS.

Alas, today I am struggling to find the good but can easily identify the bad and the ugly when it comes to the current state of affairs as we face more uncertainty.

I try not to scare-monger and still hope that some sense will come out of the Health and Social Care Bill, but I am further disheartened by the reports from yesterday proceedings in parliament. Andrew Lansley, UK Secretary of State and the Prime Minister are sticking to their guns that there is significant support for the reforms. Even though the Royal College of Nursing, The British Medical Association and the Royal College of GPs have all issued statements reiterating their concerns over the reforms, the government health team believe that the ‘listening exercise’ means everyone is now on board. Why is it that they seemed to hear something very different from everyone else?

Lord Howe, health minister exacerbated discontent by stating that it ‘mattered not one jot’ who provided NHS care.

There seems to be a reality gap here. Those of us actively involved with the NHS, either as a clinician, manager or patient all agree that changes were needed. Cost containment and service improvement are vital. But many people are now working in a state of suspended animation – decisions are being delayed until the way forward is clarified. Meanwhile Hospitals and PCTs are cutting resources, mainly staff, in response to budget demands. GP consortia – oops, sorry – the amended Bill now refers to Clinical Commissioning Groups - are nervous of investing in infrastructure for their new roles  until the Bill passes through the House of Lords – and there is no guarantee that it will emerge unscathed from its next stage.

So as far as I can see, urgent treatment is needed.

Firstly – some ear drops for Andrew Lansley and Co. to improve listening ability and maybe a special medicine that increases comprehension of the facts laid before them.

And secondly – a magic pill to release the creeping paralysis that is slowly, but surely strangling the NHS.

My day of discontent

Oh dear. It’s never good when a plan doesn’t come together. My day was well mapped out. I took the afternoon off to watch the England vs India one day international cricket match on the TV and was looking forward to a relaxing time. Alas it was rain stop play and my conscience wouldn’t allow me to ignore the fact that the recommitted Health and Social Care Bill was due to be discussed in the House of Commons.

Reluctantly – I switched over to BBC Parliament and my heart sank as I started to watch parliamentary proceedings. Like a re-run of a very bad movie with a predictable plot, weak storyline and unsatisfactory ending, I watched Andrew Lansley, UK Secretary of State for Health defend both the original bill and the 1000 plus amendments. As always he seemed confident and comfortable with his complex legislation, and still apparently blissfully unaware of the unwavering opposition to his plans.

He accused that ‘the unions, of course, are being misleading’ in their opposition to the Bill. In response to the Labour MP, Toby Perkins who reminded the House of the many and diverse organisations who opposed the NHS shake up, asking ‘Does the Secretary of State think everyone is wrong?’, Lansley smirked and said ‘you obviously haven’t spoken to all the people that I have spoken to in the NHS’

So there we have it. Same old same old. Deja vue. Groundhog Day.

Like the wonderful line from ‘Carry on Cleo’ – when Kenneth Williams, playing a wonderfully camp Julius Caesar shrieks ‘Infamy! Infamy! They’ve all got it in for me!’ Lansley simply thinks everyone else is wrong.

Alas – as the NHS continues to plough it’s directionless course we now face another round of fruitless discussion and lack of clarity.

As Nick Trigg, BBC Health Correspondent asks ‘Are we facing an Autumn of discontent?’

In short and with much regret, the answer is ‘Yes’

Is the Chief Medical Officer demonstrating bullying behaviour?

Dame Sally Davies, the Chief Medical Officer has come out fighting with her first major interview since her appointment in March. She has accused NHS front line workers who do not have a flu jab as ‘selfish’. For good measure, she has thrown in a less than subtle warning that she finds schemes in other countries where health workers are penalised for failing to be vaccinated as ‘interesting’. The UK’s top doctor goes on to blame the ‘chattering classes’ (previously known as ‘the educated middle class’) accusing them of spreading ‘scare stories’ about vaccination.

Mmm – is this a feisty, passionate medic being brave by not pulling her punches for the common good – or an opinionated, bullying boss demonstrating little thought for the individual rights of NHS staff while insulting a large swathe of the population? A bit of both I suspect.

While Dame Sally’s views are laudable and her motives sound, I can’t help feeling she has gone about this in the wrong way.

One of the fundamental errors that NHS executive management, politicians and commentators make is to morph the NHS with the people it employs. I have been guilty of this on many occasions. We refer to the NHS as a living, organic body, with one heart and brain, moving in synch like starlings in mass flight. We must remember that this gargantuan is staffed by over 1.5 million INDIVIDUALS. They are not all Florence Nightingale and neither are they all Attila the Hun. Saints and sinners, heroes and villains, committed and lazy – the NHS employs a cross section of personalities and capabilities. Yes, those who are attracted to the public healthcare sector tend to be on the more caring side of the human spectrum but they still have personal opinions and choice.

One of the better elements about planned NHS reforms is to improve patient choice. Choice – choice to vaccinate their children. Or not. And NHS staff should have the choice. Yes, by all means run a focussed, intelligent and informative education programme to ensure that all sectors of the community, staff and patients alike receive the valuable, and sometimes vital, protection from flu.

Dame Sally’s words feel dangerously like bullying to me. The Oxford Dictionary definition of bullying is ‘a person coercing others by fear’. To call someone who chooses not to have a flu vaccination ‘selfish’ is pretty strong I think. How much better it would have been to say something along the lines of ‘we believe that flu vaccination is vital to protect both staff and patients alike and we strongly urge you all to choose to be vaccinated’. Quiet and non-confrontational peer pressure could come into play as wards, departments and divisions all sign up for the vaccination.

I think it was also pretty harsh of Dame Sally to attack Tony Blair for not clarifying whether his young son Leo had the MMR or not. That is a matter of patient and personal confidentiality.

I think I am going to enjoy following this new CMO’s progress. I wish her well in her new role, but I hope she will temper her approach and tread carefully. The jury is out for now.

The difference between leaders and managers

Michael Gove, UK Secretary of State for Education has suggested that soldiers facing redundancy should be encouraged to take up teaching and help address discipline issues in the classroom.

While there is of course, political expediency behind this idea – aimed at softening the blow of military job losses, I believe there is some merit in the plan. Not just because of the potential effect on pupil behaviour – but because the public sector badly needs leaders. And many individuals who are natural leaders are attracted to a military career. Their leadership skills are then honed and put to test in extreme circumstances. Good training for a leadership role in the NHS I wonder?

The NHS employs thousands of managers. Some join with management experience, some achieve well-earned promotion and some work their way up till it’s their turn for the management pay scale level. Many NHS managers are excellent, some aren’t. But they are not leaders. Yes – there are also a few good leaders within the NHS, but not enough. Visionary and energetic leadership in hospitals, commissioning consortia and the care sector are going to be our best chance to move the state funded health provision forward.

Every organisation needs both leaders and managers. Successful organisations have great leaders supported by focussed managers. When the lines become blurred progress can be compromised. So what is the difference between a leader and a manager?

The obvious - a leader leads and a manager manages: ‘Hands on leadership’ is only of value in certain contexts. As a rule – leaders should show the way forward and provide the vision while managers create and implement the action plans required for each objective.

A leader has a vision for the long term view: Managers have to deal with the ‘now’, while keeping current activity within long term strategy. The leader sets the clear direction while the manager plans the detail.

Integrity: A desirable quality whoever you are, but transparent integrity is vital for a leader as it sets the tone for the organisation or facility that he or she leads.

Discretion and detachment: A manager can get away with sharing some tasty titbits of organisational gossip with their staff. A leader should never expose himself to that risk.

Leaders have followers, managers have subordinates. Interestingly – you follow a leader by choice, you report to a manger out of necessity.

Charismatic and inspirational: Essential for a leader, but a good manager can still perform their role well without these qualities. In a perfect world, we would want all our leaders to be charismatic. True leaders, while approachable and cordial, should still have that air of ‘difference’ – not indifference or superiority, but that ‘je ne sais quoi’ quality of authority and focus.

As John Quincy Adams, the 6^th US President said ‘If your actions inspire others to dream more, learn more, do more and become more, you are a leader’

Just what the NHS needs. So - Andrew Lansley (UK Secretary of State for Health), just as your counterpart in education is considering 'fast tracking' redundant soldiers to become teachers - how about a healthcare leadership scheme for the ex-military too?