NHS bed management - back to basics

It has emerged today that each year an estimated 400,000 discharges from hospital take place between 11 at night and 6 in the morning. Shocking as these figures seem, the reality is probably considerably less as some of the statistics include ward transfers, deaths, patient request and voluntary maternity related discharge. However for the patients involved with late night discharge, this must be a traumatic and upsetting experience.

 The spectre of a frail elderly person being bundled into a taxi and sent home to an empty house is something to be avoided vigorously by hospital trusts and admission targets have been blamed as a major contributory factor. This could well be true as Accident and Emergency departments race against the clock to admit patients within 4 hours of arrival. My stay in hospital last year involved a 3 hour 58 minute wait before I was whisked (literally – I’m sure the porter ‘driving’ my wheelchair created some serious G force with excess speed) up to my allocated bed at midnight. I must confess at the time, it hadn’t occurred to me that some poor soul had been ejected to make way for my arrival. I assumed that this was down to inefficient bed rotation.

Regular visitors (either as patient or carer) will know that achieving a timely discharge for a patient can involve considerable skill, some deception and an element of luck for the dischargee. Clinical staff, quite rightly, are cautious about letting patients in their care go home too soon and reducing the number of re-admissions is a worthy aim. However, getting someone to ‘sign you out’ can be frustrating and at weekends, nigh impossible. With fewer consultants around and the junior doctors rushed off their feet, a weekend discharge can be a thing of rare beauty. And what about the time it takes to actually leave? How often does a relative schlep up to the ward, with an optimistic one hour paid for in the car park, to be kept waiting for the best part of a day for their loved one to be ‘allowed’ home. I reckon checking out of prison is often simpler.

The system for delivering ‘TTO’s’ (take home drugs) is usually a weak link in the discharge chain and I have known patients to wait up to 8 hours simply for their prescription. Beds are sterilised between patients and delays in bed turnover are sometimes due to inefficient cleaning regimes.

As always, another story lies behind NHS statistics. Yes – of course late night discharges should be avoided, especially for the elderly and those who live alone. But efficient application of the basics could make such a difference. The basic principles of holistic care - thinking about the patient as so much more than a bed filler and considering their lives outside the microcosm of the hospital. Streamlining the discharge procedures, efficient bed changing, and slick pharmacy services would all make a positive contribution to ‘patient turnover’

Small changes can make a big difference and the patient pathway that needs close attention. As always, it is not rocket science but simple joined up thinking that needs to be applied.

Mothers – if you do just one thing today…

It’s Mothers Day in the UK today and like most mothers I shall be spending it with my family. I often feel that I should give my daughter and step daughters a gift rather than the other way around as it continues to be such an honour and joy to be blessed with this incredibly important role.

What gift could a mother give their children? A news item today recalls the sad story of Jade Goody, a TV reality star and mother of two little boys who died on Mothers Day three years ago aged just 27 years. Jade died of cervical cancer, after ignoring an invitation from the NHS to undertake cervical screening (PAP smear) and delaying seeking medical advice despite some severe symptoms. By the time the cancer was diagnosed, her disease was very advanced and she was given little hope of survival. Jade’s public persona was easy not to like. The press branded her as loud-mouthed, ignorant and racist. But she approached her terminal diagnosis with great courage, determined that other young women would not suffer the same fate and she put a considerable amount of effort into educating women of the importance of cervical screening.

Jade’s efforts paid off, and in the year after her death, cervical screening in the UK, especially in younger women, increased by a staggering 384,000(12%). As is so often the case, celebrity endorsement hit home. Three years on, cervical screening figures are still pretty impressive, with nearly 79% of women undertaking their regular tests as advised. But sadly the peak of 2008/9 has not been repeated and 250,000 less women took up their screening invitation last year. It would appear that the 'goody effect' has worn off.

Hopefully, in the future, thanks to the HPV vaccine, cervical cancer may become a thing of the past, but there are still several generations of women who need regular screening to facilitate early diagnosis, intervention and cure.

Cervical screening is free in the UK, offered to all women aged between 25 and 64. Women of any age with relevant symptoms, will also, of course be tested as needed.

So if you are a Mum who could be at risk of cervical cancer, one of the best gifts you can give your children is to be regularly tested. And if your daughters are eligible, you have a responsibility to ensure they take up their screening invitation when it pops through their letterbox. After all, looking after yourself and keeping your kids healthy must be one of the most important things a mother can do.

Happy Mothers Day!

What do nurses really need?

As usual, there have been several stories in the British press about nursing standards in our NHS hospitals. David Cameron announced that nurses will be told to do regular ward rounds, suggesting that they should check on their patients hourly to ensure high quality care.
In another report, the NHS future forum stated that nursing training has become ‘too academic’ while at the same time reporting that some nurses lacked basic skills, have a poor grasp of maths and do not understand the values of the health service. The report goes on to say that ‘selection in nursing …. has moved away from selecting students on their ability, capacity for compassion and caring and desire to work in nursing’

None of this will come as a shock to anyone associated with the NHS. But what is strange is how government, watchdogs and ‘health leaders’ seem to be going about addressing the issue.

I find it a little odd that the Prime Minister should get bogged down in such detail as a ward round. In fact – I suspect he isn’t even clear on what a ward round is.

I have written before about the farce that is a ward round in many facilities - a hotchpotch of ‘health workers’ with neither badge nor recognisable status, standing at the end of a poor patient’s bed, discussing them as though they don’t exist and even getting their name wrong.

Likewise the NHS Future Forum suggesting that nurses should be assessed for their capacity for compassion. How do you measure that?

Nursing is a profession. It is a profession that requires intelligence, physical ability, emotional strength and a genuine interest in the health and wellbeing of the people in their care. Nurses’ pay in the NHS really isn’t that bad. Truly. It’s not. But it’s not an easy job, particularly in the current NHS environment of limited resources, proposed cuts and most of all, uncertainty. It's a job that can be physically and emotionally draining and I can completely sympathise with nurses who bemoan their lot. It must be very tough right now.

So what do nurses need? I had a very interesting conversation with a senior nursing leader who has worked in the public, private and community care sector and I absolutely agree with her. She reckons that what nurses need most of all is support and leadership.

It’s not for the PM to decide how often a nurse should check a patient. It should be down to a ward sister, matron or whatever you wish to call the leader of the unit. That leader should nurture a culture of care and compassion, of good customer service and excellent medical practice. That leader should discipline the work shy, weed out the bullies and encourage those who need and want to improve. But most of all, the leader in charge of the ward should take personal responsibility to nurture the nurses and carers. Like a good parent, they should be firm but fair, lead by example with resilience and treat everyone with kindness and professionalism.

Come to think of it – that’s what patients need too….

Faulty breast implants – this isn’t just about silicone.

Silicone implants have been a big news story in the UK for the past few days – and not because just about every female contender in the latest series of ‘celebrity’ big brother appears to be sporting a pair of ‘plastic’ appendages.

A recent report has confirmed that PIP implants, currently nestling in 40,000 chests in the UK, are faulty, could possibly rupture and consist of  ‘non-medical’ grade silicone, of the type normally produced for mattress stuffing.

The really interesting bit is what happens next. How would the government react? Would the private sector step up to the plate (95% of these implants were fitted privately) and accept a level of responsibility? And what about the women walking around with a potential ticking time bomb lurking within what they clearly believe to be their greatest assets?

This is a situation about culpability, blame and ultimate responsibility. I wasn’t actually going to blog about this story until I received an email from one of my followers, a normally easy going lady of measured opinion. ‘Ok blogger lady...no idea if you have an opinion on the issue …. I do not feel that it’s right that the NHS foots the bill for the exploding boob saga! Surely the private companies who stuck them in should have to replace them?’

Nicely put – ‘angry from Amersham’!

Authorities in France, Czechoslovakia and Germany have recommended that the implants should be removed. Andrew Lansley, UK secretary of state for health, wisely took some time to ponder his recommendations. If he agreed that all PIP implants should be removed – who should pay for this? Only 5% of the implants were funded by the NHS, presumably for sound clinical reasons, such as reconstructive procedures following surgery for breast cancer. No-one could deny that these patients deserve fully funded support and replacement of the faulty inserts. But what about the remaining 95% who chose the surgery for cosmetic reasons? Where do you draw the line for the NHS to ‘mop up’ complications following procedures undertaken privately?

I fully agree with Andrew Lansley’s recommendations (and it’s not often you hear me say that in this blog). Anyone who received the implants under the NHS should be offered replacements. I also agree with his comments – ‘We believe that private healthcare providers have a moral duty to offer the same service to their patients that we will offer to NHS patients - free information, consultations, scans and removal if necessary’

So far the private sector is making all the right noises, with the clinical director of one group, Spire Healthcare saying ‘We have a duty of care to our patients’ and Nuffield’s group medical director saying ‘We believe there is a strong case for the private healthcare industry to pull together to resolve this matter in the interests of patients’.

One could argue that this rather tiresome tale of a faulty medical device that will only affect 0.07% of the UK population is occupying too many column inches and too much airtime. But it is the bigger issue that is being questioned here – the fine line between responsibility and ownership of patients when they are treated in both the public and private sector.

I would like to see two outcomes from this recent problem.

Firstly, if treatment which takes place privately is not eligible within the NHS, such as for cosmetic purposes, these procedures will normally be self-funded, as they are unlikely to be covered by private medical insurance either. In these circumstances, I would like to see a mandatory indemnity insurance payment, to be made by the patient, to enable funding to reimburse the costs for emergency or follow up treatment, wherever it takes place.  Yes – this will make cosmetic surgery more expensive but it will introduce a safeguard against future controversy like the PIP implant dilemma.

Secondly, and this is a personal view, it would be good to see fewer women, whatever age, with fake bosoms. Stick to what Mother Nature gave you and be grateful for your good health.

Caesareans on demand. ‘Nice’ to have but not need to have?

The National Institute of Health and Clinical excellence (NICE) has issued some new guidelines advising that pregnant women should be allowed  to choose caesarean delivery, paid for the NHS, even if there ‘is no medical need’

As always, I am writing this post with all hats on – mother, clinically trained, healthcare manager and commentator. Let’s start with the mother bit first. Childbirth, like so many other experiences, can be dramatically influenced by perception. My mother, bless her, told me that giving birth was ‘easy as falling off a log’. A strange saying as I don’t know anyone who has actually fallen off a log, but I guess that if you chose to do such a foolish thing – it would be easy. I was very fortunate to produce a tiny baby who was in a hurry to be born so it was just as dear Mama said – a doddle. But I won’t deny that it was a painful doddle.

I would not for one moment belittle anyone who has fears or concerns about natural labour. Neither would I dispute that C sections can be life saving and vital in some cases. But to choose to have surgery simply because you can, really isn’t good enough. Pregnancy is usually an active choice. Even unplanned reproduction is often a result of a choice not to be more careful! With choice comes responsibility. We are already very fortunate in the UK to have access to free maternity services. Those free services, up till now, included the reassurance that either a planned, medically necessary or unplanned emergency Caesarean would be offered. So prior to these new guidelines, mothers being cared for within the NHS would expect to have to go through natural labour unless sound medical reasons existed.

NICE recommends that mother’s considering to opt for a C section should receive counselling from a midwife. That seems sensible until you look at resources currently available. Just two months ago, the Royal College of Midwives warned that some areas of the country face ‘dangerous shortages’ as the number of trained professionals has not kept pace with the rising birth rate.

This is where all my other hats kick in. Yes – in a perfect world patient choice would be absolute, although the wisdom of choosing major abdominal surgery when not essential could be questioned.  But we don’t live in a perfect world. Especially in the land of healthcare. Midwifery resources are already stretched, so how can this counselling realistically be offered? NHS Hospitals are severely stretched so how can it be sensible to offer a potentially huge number of extra surgical interventions with the resulting increase in bed occupancy and procedural   costs?

Every treatment option must be considered in the context of medical inflation and the dire financial straits of the NHS. It isn’t helpful to those trying to balance the books when an official body eases open a potential floodgate of cost and resource pressure.

As the NHS faces it’s most drastic reform and cost cutting measures, all agencies must try to work within the context of this reality.

We don’t just need joined up care – we need joined up thinking.

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.

Commerce has its part to play in keeping NHS costs down.

It is widely recognised that the biggest challenges facing the NHS are rising costs of medical innovations and care, and the ticking time bomb of a nation making unhealthy lifestyle choices. The population will live longer but in a less healthy state, due to increased incidence of diseases such as cancer, diabetes and heart disease, linked to inactivity, bad lifestyle habits and obesity.

As we all know, these challenges provide the context of the NHS reforms proposed by the UK Secretary of State for Health, Andrew Lansley and Public Health initiatives are key to the future viability of state funded healthcare.

This is where commerce and industry comes in. Employers face the same conundrum as NHS leaders - how can they keep their target population healthy, and reduce the costs of healthcare to their organisation. The costs to commerce include the effect of medical inflation on health insurance claims and premiums for their insured employees, the economic burden of illness-related absence affecting all staff and the impact of presenteeism, where an unwell employee stays at their desk often due to insecurity or work pressure.

This is a good reason to keep a close eye on the US health system. President Obama’s healthcare reform, The Patient Protection and Affordable Care Act (PPCA) puts the onus of health care costs for employees and their dependants squarely onto the shoulders of employers. Already motivated to keep their staff healthy for altruistic and economic reasons, this additional burden has certainly focussed employers’ minds on creating a healthy workforce with the aim of reduction in costs and increased productivity.

Motivating leaders to invest in wellness programmes and incentivising employees to adapt their behaviours is a high priority for all forward thinking organisations both sides of the Atlantic. I am attending the US Corporate Wellness Conference in Chicago next week to monitor the views and opinions of those tasked to tackle this major issue. The theme this year is ‘Progress in motion – creating a healthy culture’.  Sharing of this knowledge between companies and continents is crucial in bringing some control to the accelerating juggernaut of health inflation and a generation of individuals with destructive lifestyle behaviours.

In the US, companies are obliged to address healthcare costs thanks to the PPCA. In the UK, there are very good socio-economic reasons to do the same. Most successful workplace healthcare initiatives can be mirrored by public health leaders for the population at large. And every penny spent on improving health in the workplace will either indirectly or directly have a positive impact on savings for the NHS and the wellbeing of the nation as a whole.

Waiting times target manipulation - another tale from the front line

Since starting this blog, those involved with healthcare regularly contact me with tales from the front line – good and bad. One thing I always guarantee is anonymity and the other rule I have is, of course, to check authenticity as much as possible.

A young booking clerk, currently working for a Trust which aspires to Foundation status has told, with some distress, that she is about to hand in her notice. The reason for this is ‘I didn’t join the NHS to do this sort of thing – it’s wrong – I feel so sorry for the poor patients’

And what is ‘this sort of thing’?

The girl was told by her manager to phone up many of the people due for surgery this week and postpone their booking. These patients will all have had their pre-op checks, will have made personal arrangements for their hospital stay and will have been psychologically preparing themselves for the event. What is so unusual about cancelling operations you may ask? In this case – it’s the reason for the shuffle in operating list that caused this clerk some concern.

The patients who were being cancelled have all been on the waiting list for more than 18 weeks (exceeding the current target). The clerk was advised to call up a new group of people offering surgery to be undertaken in the newly vacated slots.

The new group of patients given the advantage of using these new slots have all been on the waiting list just less than the 18 week target. The motive quickly becomes clear. Those who have already exceeded the target will have been noted in the stats – those just about to reach the 18 week cut off will narrowly miss the deadline and avoid worsening the Trust’s waiting list figures.

I’m not sure if this tale is shocking or not, probably even old news, but it is certainly very sad. Presumably the motivation behind this action was to avoid further financial penalty and possibly aid the Foundation Trust application. Anyone involved with targets in any industry will do their best to present the figures in a favourable light but this must not be to the detriment of individual patients. I wonder what sort of pressure whoever made the decision to fudge the figures must have been under, especially as this will have caused considerable distress to some patients and maybe put them at risk.

The actions of this hospital trust in disadvantaging some patients to expediate targets shows that in the red mist of pressure, cuts and politics, hospital and healthcare providers may be losing sight of the core values of the NHS. Outcomes, targets, performance measures – call them what you will – these benchmarks will always be associated with healthcare. But we must not let the desire or need to hit targets distort the very heart of what we are here to do - help people to get better and keep them well.

Ministers behaving badly must go.

I try to keep this blog apolitical and would struggle if pushed to give an allegiance to one party. So I am writing this post as an independent observer disappointed with three of her majesty’s government ministers. I am also writing as a healthcare evangelist – and it is impossible to separate health and politics right now.

I won’t delve too deep into today’s resignation of Liam Fox, the Minister for Defence, as there is blanket coverage already available. At best – he showed very poor judgement - at worst, broke the mistrial code regarding conflict of interest. But either way – you don’t take your mates to work with you – do you? Ministers are, or should be, leaders. And leadership can be a lonely role. I must confess that when I was an employed director I would have quite liked to have a friend in tow – even my Mum sometimes! But it’s simply not done.

Then – even more bizarrely – we have the case of Cabinet Office Minister Oliver Letwin disposing of sensitive government documents in a park litter bin on five separate occasions. What?? I’m not a particularly over cautious individual but I shred any bill with my details on it and burn client information of it’s no longer needed. I would never, ever, ever dispose of anything remotely private in a public bin! Letwin is guilty of extreme stupidity. If his judgment is so poor on something as fundamental as confidentiality – Heaven knows what other imbecilic things he gets up to. He has to go

And finally – oh dear. Andrew Lansley – the beleaguered Health Minister. I have no doubt that Lansley is an honourable and intelligent man who genuinely believes that his reforms are the right way forward. But for nearly a year now he has consistently ignored the views of the experts in health – the consultants, nurses, GPs, therapists and managers who all tell him that the Health and Social Care Bill isn’t the way to solve the NHS woes. He is fixated on a solution that does not actually address the problem and this intransigence is now actively damaging the state provision.

But the killer blow for me was Lansley’s performance at BBC’s flagship discussion programme, Question Time. Questions are posed by a public audience to a panel of politicians and ‘thought leaders’ and the audience have an opportunity to join in the debate. With Lansley on the panel, of course health came up. The question logically enough was something along the lines of ‘when so many medical institutions and clinicians are against the NHS reforms, is it wise to go ahead?’ Lansley’s response was measured. Then a member of the audience, a health worker, very calmly and eloquently gave her opinion, finishing with ‘Mr Lansley, I don’t trust you’. I’m not sure if Lansley knew the camera was on him – but he sneered at this woman with undisguised contempt.

It was actually quite chilling. Twitter went ballistic demonstrating very clearly that I wasn’t the only person to notice that the one thing NHS staff and Andrew Lansley have in common is a mutual and reciprocal dislike and disrespect. In that split second, 8 million viewers saw what Lansley thinks of many of the 1.5 million NHS workers for whom he has a responsibility. He is so disconnected from this population and apparently dismissive of their views that he didn’t even hide his feelings.

If a CEO of a large corporation loses the respect of his staff and ploughs a furrow not in the best interest of that organisation – the board would normally dismiss him. And so it is with the UK Secretary of State for Health.

It’s time for Andrew Lansley to go.

Andrew Lansley fails to ignite the Tory Party Conference

Lansley fails to ignite the conference.

Sad as I am, I sat in front of the TV in rapt anticipation for Andrew Lansley’s Tory party conference speech. I wrongly assumed that the contentious Health and Social Care Bill would be high on everyone’s agenda but the conference hall was only half full as the audience awaited the Health Secretary’s appearance.

The choice of music just before the start of the session was bizarre – Shawn Mullins’ song ‘All in my head’ with the lyrics:

‘Is it all in my head?

Is it all in my head?

Could everything be so right without me knowin’?’

The song goes on:

‘Everyone needs a little love – to make it all work out..’

Was this a subliminal plea to the Tory faithful to be kind to their beleaguered reformer?

Lansley gave, as usual, a polished performance. Quoting many of the good work going on in the NHS and it was notable how often the N word was mentioned. Nurse. Lansley has realised that bigging up GPs as the only clinicians who count with the initial draft of the bill was a fundamental error.

The audience was as lukewarm as a cup of tea left by an old lady’s hospital bed. Ripples of polite applause interspersed the usual sound bites but to be fair, I found the Health Secretary more convincing that normal, especially when discussing outcomes and integrated care.

He received the mandatory standing ovation, albeit very muted – and I couldn’t help wondering if the delegates were stretching their legs after a long day sitting in conference rather than getting excited about a Bill that could cost them a second term.

The panel who joined Lansley were actually more convincing. An amazing nurse called Vicky Bailey spoke with great authority about practice based commissioning and the excellent work that her organisation, Partners in Health, had achieved with integrated care.

The next speaker, Neil Bacon, was billed as ‘a doctor and entrepreneur’. Yes. I’m judgmental and yes I mentally switch off when anyone refers to themselves as an entrepreneur.

Another nurse, Sylvie Hampton spoke with true passion about her wound healing social enterprise, while turning a few gills green by showing an explicit slide of a nasty wound. This speech described a great example of the value of private providers as she demonstrated the high quality cost saving treatments her organisation offer. Sylvie is a powerful advocate for ‘any qualified provider’ and went on to say that her team were ‘a new breed of private provider to the NHS – anyone who thinks this is privatisation is nuts’

And then it was business as usual as Simon Burns, huffed and puffed his way through his presentation. There is always something of the pantomime about this health minister and he didn’t disappoint as he raged about how the reform plans have been ‘discounted by those with an axe to grind’’

It was interesting to note that the most positive and memorable messages came from the two nurses who described the success of their services so effectively. More interesting was the fact that both these initiatives were in place long before the Health and Social Care Bill was a twinkle in Andrew Lansley’s eye.

Vicky Bailey’s initiative was in her words ‘nothing new – we’ve been doing this since 2006’. And Sylvie Hampton’s company first did business with the NHS in 1999.

The words of Shawn Mullins song, played just a hour earlier sprang back into mind..

 ‘Could everything be so right without me knowin’?

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.

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?

New Term, new habits

Forget the weather, there are two ways that I am reminded that Autumn is on the way. Firstly, the football season starts, and watching Manchester United’s first home match at Old Trafford brought back the familiar thrill and anticipation of many injury-time goals to come. Secondly, not so exciting – the shoe shops are full of Mums buying school shoes for their children.

Remembering that ‘new school year feeling’ – new shoes, a blazer three sizes too big and lots of pristine pens and exercise books, as always, I turn my thoughts to health. The NHS is facing it’s most challenging term of all and maybe now is the time to suggest some new habits that all of us could adopt to improve patient care and enhance the efficiency of the services we provide. This list of ‘new term resolutions’ is applicable to us all involved in the future of our state funded health system – Health administrators, nurses, doctors, therapists, commissioners, community workers – all 1.5 million of you (or however many are currently employed in the NHS)

Be nice:

Yep – I’ve said it before and I’ll say it again. Rude emails, bad behaviour in meetings, a curt tone with confused patients really should have no part in the business of healthcare. Of course, we are all human, and have the odd off-day, and I can hold my hands up and admit that I have given colleagues short shrift before, but I do try not to make a habit of it.

Respect each other’s profession:

We all have a part to play in making the NHS great, all of us. A patient needs a pharmacist just as much as he needs a doctor, care worker or even hospital chef! And whatever you do – don’t criticise a colleague in front of a patient.

Remember that not everyone knows what you know:

I have blogged before about assumptions in healthcare, and assuming knowledge or understanding is one of the biggest dangers for integrated care. If a patient or colleague appears confused, take the time to bring them up to speed. But also remember that they might, and in fact do, know plenty that you don’t know!

Give up jargon:

One of the most annoying aspects of the NHS is the jargon they use. A few years ago the Daily Telegraph  printed some examples of confusing language used for patients – including one letter to a patient signed by ‘your intestinal failure coordinator’ and another being told that their case was ‘embedded within an indication of needs matrix’ Aaargh! .The NHS Information site lists in excess of 500 acronyms currently used including HAZ (Health Action Zone) and WIRG (Workforce Information Review Group) When I first started running projects in the NHS, I was constantly online trying to decipher what people were actually saying to me!

Make your meetings count:

Strong meeting management, decent preparation beforehand, good timekeeping and clear goal setting could transform the approach to many administrative and clinical issues.

Take pride in your environment:

One particular bugbear of mine is scrappy notices, often in health centres, stuck up in public areas, with tape – crooked, out of date or irrelevant. Regular readers will remember my pain at the tissue left on the floor of a busy ward, ignored by all comers. Own it – own your workplace and look after it.

Think ‘integrated’:

The single most important habit to adopt. I am delighted that the NHS Future Forum has added a fourth workstream – focussing on integration. I’m less happy that the co-chairs are the Chief Executive of a Borough Council and a Commissioning GP. What about those big buildings with beds and patients in them – a key part of the integrated pathway? Hopefully there will be plenty of hospital professionals included in the working group. The key to cost savings, improved outcomes and efficient patient care is to consider the entire patient journey. Yes, I know I am becoming a bore on this - but if you have to adopt just one good habit for this new term, this really should be our top priority.

As Aristotle said, ‘Quality is not an act – it is a habit’

So, before the harvest is safely gathered in and the chestnut trees begin to drop their conkers, let’s keep the good habits we already have and start the autumn term with some new ones too.

Hush, hush whisper who dares?

When you are a parent you quickly learn from the toddler stage right up to late teens – if they’re not making a noise, they’re probably up to no good. As you try to track down your silent, but potentially deadly offspring you hope that whatever you find won’t involve too much mess or damage or a trip to accident and emergency department.

Speaking of which…

There is an uneasy quietness about all things NHS at the moment. Yes – it’s the silly season for news, and of course recent yobbish behaviour in the UK and the global financial challenges are taking up most of the serious headlines. But as our attention is briefly diverted – the time bomb known as the Health and Social Care Bill continues to tick….

Sitting quietly and unobtrusively in the House of Commons, the controversial Bill faces one more report stage and final reading on the 6^th and 7^th September. Then the NHS reform plan, the rather bloodied and bruised brainchild of Andrew Lansley, UK Secretary of State for Health, will start its journey through the House of Lords. This could be interesting and I suspect there is little chance of simple rubber stamping at this stage.

In the meantime, what’s happening at the coalface?

Yes, there is still a huge amount of excellent care being provided by many well-managed units across the patient pathway. But signs of financial pain, limited resources and most of all, a creeping (or is it galloping?) uncertainty are beginning to show.

The audit commission has warned that a quarter of NHS Trusts have ‘notable weaknesses in their arrangements for securing financial resilience’. Although £4.3bn savings were delivered in 2010/2011 through ‘clinical productivity and efficiency’ 19% of targeted savings were not achieved.  It was judged that 23% of savings were ‘one-off fixes’ such as temporary recruitment freezes, and not long term strategy.

This coming fiscal year will be much tougher and the audit commission states ‘Organisations that have up to now managed their finances well will find financial pressure increasing as the need to deliver high quality services without the funding growth will begin to impact’ .

Jo Webber, deputy director of the NHS Confederation fears that this could be ‘the calm before the storm. Many of our members have told us that they are expecting the financial situation facing their organisations to be the worst they have experienced’

All this in the context of ever increasing demand on resources.

So that’s what the silence is – people holding their breath as they tighten their belts…