Is sentimentality getting in the way of progress for the NHS?

As predicted – there has been much ruffling of feathers and beating of breasts following the coalition’s announcement that a private health partnership Circle, will take over the running of the failing NHS Hinchingbrooke Hospital, near Cambridge.

‘No-one should make profit from health’ said Terry Christian, TV presenter on a daytime chat show. Liz Kendall, shadow health minister is ‘deeply worried’. ‘An accident waiting to happen’ warns Christina McAnea, from the union Unison.

In a £1bn deal, Circle has 10 years to run the hospital, which is currently £40m in debt. This debt has been accepted by Circle as part of the deal.

Perhaps the nay-sayers to this franchise agreement should hold their horses for one cott’n pickin’ moment. Let’s look at the facts…

Hinchingbrooke Hospital serves a community of over 150,000 people. A community who vehemently want their hospital to remain open, delivering care ‘free at the point of delivery’ as per the NHS founding values. Hinchingbrooke Hospital has been ‘failing’ for years. Failing to reach minimum standards in quality, safety and financial control. The hospital has floundered under a succession of NHS management teams who failed to take control of the escalating debt, poor morale and falling standards.

My grandmother had a saying ‘never throw good money after bad’. There was a growing pit of debt at this hospital. Something had to give and there were three options. Try yet another NHS management team, close the hospital, or put the management of this wounded beast up for tender. The third option had to be the best choice, although in true NHS fashion – the tender process took over 18 months, as money and quality dripped away in Cambridgeshire.

The appointment of Circle health partnership is, I think, courageous and worthy. Their track record in running hospitals is good so far. Their approach of partnerships – so effective in organisations such as the retail giant John Lewis, sits comfortably with NHS principles. And I think they have a very good chance of turning the hospital into an efficient, high quality care provider. Yes services may need to be rationalised – but show me an NHS hospital that isn’t going through rationalisation.

What are the real dangers of this decision? Not many in my opinion. There is an opt-out clause so the government can pull the contract if sufficient progress isn’t made. There must be regular and effective lines of communication between the NHS and its franchisee.

‘No front line jobs will be lost’ according to Simon Burns, health minister. I see that as a potential negative rather than a positive. One of the biggest problems with the NHS is the lack of performance management in some areas. I would like to think that Circle will ensure that staff perform to the standards required and poor attitude or performance is not rewarded with continued tenure.

The main ‘danger’ I perceive? Sentimentality. Speaking as one who is dreadfully sentimental (bereavement, age, parenthood are my excuses) – I feel we really must put sentimentality aside in this case. ‘Save our NHS’ is a popular Twitter hashtag, and I don’t think anyone would argue with that particular sentiment. But trusting the management of a failing hospital to an existing failing system for sentimental reasons just isn’t good enough.

Yes – I do get very sentimental about the NHS, especially when I comment on the Health and Social Care Bill, which I believe will do harm to the state funded care system in general. But when bits are broken and need fixing – sometimes you need to look further afield for the best organisation to do the job. And if Circle make some profit AND save a hospital, turn around £40m debt while providing cost effective high quality care and keep good staff in their NHS jobs - good luck to them.

NHS – Is the mood of the employees affecting progress?

Linkedin professional groups seem to indulge in discussions ranging from the banal to the fascinating and one recently started by NHS Professionals Network sits somewhere between the two.

The question posed was: ‘What one word best sums up how people who are working in the NHS feel at the moment?’

On the face of it – an interesting conundrum to while away a couple for minutes of boredom at the pc. The discussion point prompted a myriad of replies giving a thought provoking insight to the diversity of agendas of those associated with the state health provision. All comments were personal, some selfish, some insightful, some ridiculous and some didn’t even follow the rules and used more than one word!

The personal ones, which appeared to be talking about the individual rather than ‘people’ included such plaintiff wails as ‘Bedraggled’ ‘Undervalued’ ‘Disillusioned’ and ‘Bullied’. Ouch.

Others wanted to display their command of the English language with ‘Somnambulant’ ‘Discombobulated’ (which means state of confusion – I looked it up). A few hopeful, positive souls used ‘Resilient’ Opportunity’ and ‘Interesting’

Others used the platform to vent their particular frustrations or promote their businesses. Interestingly, none of these self promoters could manage that in one word. A few brave souls commented ‘let’s stick to the question’. My point entirely. But what does this all mean?

I think this discussion thread sums up perfectly the biggest challenge facing the NHS. There are so many personal agendas coming into play. There is nothing wrong with looking out for yourself, especially as most employees within the NHS also care deeply about their jobs and the people in their care. But where is the shared vision? When I first read the question, my immediate thought would be to answer it on behalf of all people working in the NHS, to try to capture the mood, and some of these one word answers have achieved that.

But where is the consistency in views? Read any management manual on successful team building and without fail it will stress the value of a shared vision.

As Winston Churchill said ‘The empires of the future are empires of the mind’

In my opinion, one of the most vital areas for reform in the NHS is the mindset of individuals and the emotional intelligence of the organisation as a whole. It is entirely understandable that there are so many differing views, even in this straw poll. But as a matter of urgency, the leaders within hospitals, care centres, remaining Primary Care Trusts and all other areas need to find the Winston Churchill within and lead, encourage and motivate.

I was heartened by a lovely comment on this Linkedin discussion by a nurse, Jan Potts who posted:

‘When the going gets tough, the tough get going, come on guys take some control here, when its been bad before admittedly not this bad the best innovation has appeared. Think of the things that are going well and build on them however few they maybe at the moment. Never give up’.

Well said Jan.

And my one word answer to the original question? ‘Surviving’

In healthcare it’s often the small things that make a big difference.

I was heartened to read a news story yesterday about the use of painkillers for patients suffering from dementia.

http://www.bbc.co.uk/news/health-14138884

Agitation is commonly associated with dementia and often treated with antipsychotic drugs which can accentuate the symptoms of the condition and cause excessive sedation. These drugs can rob Alzheimer’s or dementia patients of the last vestige of interaction with the world around them and reduce them to ‘zombie’ status.

One of the tragedies of dementia is that a patient is unable to tell his or her carers how they are feeling and bearing in mind that many elderly people experience painful arthritis or similar conditions, it is logical to assume that a high proportion of patients may be suffering undiagnosed pain. 

In a recent study, researchers the UK and Norway found that there was a 17% reduction in agitation symptoms in dementia patients given painkillers.

This is a wonderful initiative in easing the suffering of our most vulnerable patient community. My mother suffered from dementia for nearly ten years before her death but was fortunate to be cared for by an amazing team of people. During a routine discussion on her care, the matron advised me that they were giving my mother paracetamol four times a day. I asked them how they knew she needed this medication and they simply said – ‘her joints look painful so we thought it best to see if we can ease her discomfort’. The transformation was dramatic. Within a few days she was calm, and content. Her antipsychotic medication was discontinued and she became more alert and aware of her surroundings. I wrongly assumed this was standard practice so I am delighted to see that this ‘breakthrough’ is being made public.

How often we find a simple solution to a complex problem.

Andrew Lansley, please take note – to improve care and outcomes – you don’t always have to deliver complicated and expensive strategies. Keep it simple!

NHS Reforms – who do you believe?

I took an active decision to limit the number of postings on NHS reforms recently as I was worried I would start to bore my readers (and myself) as I tried to unravel the fact from the fiction and unbiased judgement from personal opinion. I thought I would enjoy my own version of ‘listen, pause, reflect and improve’.

I had no idea that the News International hacking scandal would provide me with a welcome diversion and potentially rich seam of material. Who could have thought that the dishonest and illegal activities of a bunch of (in my opinion) seedy and amoral perpetrators could be seen as light relief compared to the current state of the Health and Social Care Bill?

But where are the rights and wrongs on NHS Reform? There remains an uncomfortable lack of clarity. Still under discussion, each day a new list of submissions and comments regarding the amendments to the Bill is published. These include contributions from bodies such as the Royal College of Surgeons, Chartered Society of Physiotherapists and National Voices (a patient advocacy organisation). Many of these submissions feature statements of support for the revisions to the Bill, mostly tempered with additional recommendations or reservations.

Today, the Royal College of General Practitioners (RCGP) submitted their comments which make very interesting reading. Included is a survey of their members where 85% of respondents stated that they were not reassured by the planned amendments to the Bill. Over 50% disagreed that the revised model of clinical commissioning groups would lead to a patient led NHS, improve patient outcomes or reduce health inequalities. Conversely, the body of the RCGP response includes the phrase:  ‘We welcome placing General Practitioners (GPs) at the heart of planning services for their patients, and increasing professional and patient involvement in health service design and funding decisions…’

Likewise with statistics on the current state of the NHS. The Guardian website (http://www.guardian.co.uk/) datablog has outlined some fascinating discrepancies on statistics – all true, but presenting a very different message. The Guardian quotes Lansley, UK Health Secretary - ‘Waiting times have been kept low, with the average time patients wait for their operations lower’. Closer inspection of statistics shows that the number of patients waiting in excess of 4 hours in Accident and Emergency has increased by 76% and that an extra 2,400 patients every month are waiting for more than 18 weeks for treatment compared to last year.

What does all this conflicting evidence and opinion mean? Time, and hopefully statistics,  will tell. The listening exercise and Future Forum consultation process has had a positive effect in forcing the government to amend some of the reform plans. But what happens as the Bill proceeds through parliament and on to the House of Lords continues to challenge commentators and those tasked with implementing the changes.

Give me a good old fashioned scandal any day…..

My birthday wishes for the NHS

So the NHS celebrates her 63^rd birthday today. She’s a little battle weary and ragged round the edges, but as every aging film star will tell you – 60 is the new 40 and she’s a game old bird with plenty of life left in her – we hope. She’s a bit old-fashioned in some of her ways, but has embraced technology in many areas and has been a key driver and pioneer in medical research and treatment innovation. She’s got a good heart and has been doing her best, coping with diverse masters. If only I could – these would be my gifts for the state funded health system.

Clarity: However the reforms pan out, as the listening, tweaking, and reviewing continues, I wish for a clear instruction and guidance from the Health and Social Care Bill. I would wish for ‘Limbo land’ to be brought to an end and a clear picture of how the NHS will operate to emerge. Soon.

Rejuvenation: So much about the NHS is tired, the buildings, the people, clinical staff, managers, support workers. There are significant new, well equipped facilities to be celebrated, but dilapidated and shabby amenities, including community centres and hospitals remain. This isn’t just about money or resources. It’s about taking care of your workplace and your colleagues.

A communications trainer for every facility: Now wouldn’t that be great! Administrators could be taught how to relate to their peers, nurses to doctors, doctors to patients, Chief Execs to commissioning boards, hospitals to their community, carers to relatives. The list is endless. The key to the utopic vision of integrated pathways is communication.

Tolerance: I believe that one of the most damaging impacts of the NHS Reform plans so far is the divisive effect in creating conflict between clinical peer groups. GPs and Hospital Consultants feel they have to compete for funds and the potential shift of power is uncomfortable for many. A variety of stakeholders feel sidelined and undervalued. As resources are stretched, tolerance levels between colleagues and even tolerance for patients is tested. A little tolerance for the private sector wouldn’t go amiss either. Competition is here to stay, better to embrace it, and use quality assured external providers wisely, to reduce costs and mange capacity issues.

Innovation: One of my biggest fears is that the reforms may undermine the opportunity to innovate. Ground breaking treatments, innovative regimes and new techniques are better to be tested in the NHS than anywhere else.  A precious birthday gift indeed.

Performance Management: Not much of a gift some would say. But we cannot escape the fact that a public sector job is not a sacred cow. Poor management, sloppy clinical practice, or substandard work should be properly addressed.

And finally…

I wish the NHS a long and healthy life and many happy returns!

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.

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.

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 2^nd 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.

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.

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.

http://www.itv.com/news/cameron-ordered-out33095/

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.

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.

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!

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 …

‘How’

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

    delivery.

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.