Football, Bullying, Leadership, Role models

An incident in last night’s football match between Chelsea and Swansea City touched on my favourite topics – Leadership, Bullying, Role Models in the Workplace and Football.

The incident involved a Chelsea player, Eden Hazard who kicked a ball boy as he lay on the ground. The 17 year old son of the Swansea City Director annoyed both home fans and players by holding on to the ball too long as he attempted to wind down the clock for his team. Viewing the replay, Hazard delivered quite a hard kick and the boy’s body was squarely between the Chelsea player’s boot and the ball, so the outcome of the kick could never have been in doubt. Hazard defended his actions saying that he had not intended to kick the boy ‘…I was just trying to kick the ball’. Mmm -  a bit like a wife beater saying his prey’s face got in the way of his fist.

The spectacle was bad enough but the mixed reactions from those involved with the sport are even more shocking with several ex-premier league players saying that they would have done the same in similar circumstances. Yes the lad was trying to cheat by time wasting, but does that justify physical violence? I think not.

Alas, not only does this sad story demonstrates how far our national sport can fall from ‘the beautiful game’ to an ugly spectacle. It is also a depressing example of how an organisation’s leadership and culture spills down throughout the ranks.

Football is now spattered with undisputed cheating, poor behaviour, bullying and dodgy practice. Maybe this young lad felt that time wasting and exaggerating his pain is acceptable as he watches his heroes regularly dive to win penalties, feign injury as they clutch their undamaged faces and abuse match officials. My love affair with football, which has spanned four decades, is now seriously compromised as players and their clubs continue to disappoint. 

As I have written before – a professional football club is an employer, and the pitch is the workplace. If a junior clerk in a shipping company skives off and comes back late from lunch or messes up an order is it acceptable to clip him round the ear? Of course not. Positive workplace behaviour is bred from strong leadership and positive role models. Strong leadership is not the same as bullying and a good role model should be more than just talented at their job.

The power of football isn’t only about the vast sums of money involved – it is also based on the millions of fans who can be influenced by the sporting heroes on, and off, the pitch.

Strong leadership? Let me think – how many managers has Chelsea Football club had over the recent past? 8 different managers in five and a half years. Does that make the owner of Chelsea FC, Roman Abramovich a strong leader or a bully? Does that type of leadership generate good behaviours on and off the pitch?

Of course Chelsea aren’t the only culprits so I make a plea (yes I know this may be a little naïve) to all employers – lead well, behave with fairness and honour, and you may be pleasantly surprised with the results.

 

Caremakers – the NHS must make sure this isn’t an opportunity missed.

I fear for the future of nursing. Angels or devils, nurses are the front line staff who define the patient experience. The Royal College of Nursing’s new 6 C’s initiative spells out the danger signs in patient care. Anyone interested in care will have already heard of  the 6 ‘values and behaviours’ defined by the RCN - Care, Compassion, Commitment, Courage, Communication and Competence. One could argue that these should all be a given, not some new idea. What nursing needs is clear leadership at ward or unit level, not more sound bites and jargon.

What makes a good care experience? A well run ward. What makes a well run ward? A good leader. What does a leader need? Teams with clearly defined roles.

A family member recently experienced NHS care and felt that there were plenty of nurses on duty, but care was not great. He was left bleeding profusely and choking on the blood while the A & E nurse handed him some paper towels and then went back to reception to chat. It's easy to blame staff numbers for poor care but nursing shortages are not always the cause when standards slip.  

As I have blogged often, for every bad care experience there are multiple stories of all 6C’s way above and beyond the call of duty. But how can we bring this back to be the norm and not judge basic care as a luxury?

One suggestion is that 1000 ‘caremakers’ posts are created. ‘Great’ - I thought until I read that this role would be extended to experienced nurses. Ahem – isn’t this a bit like saying from now on we are going to make sure that all our bus drivers can drive a bus?

Just because nurses are now highly qualified and hold expert medical knowledge doesn’t mean they no longer give care. The same should apply to doctors and therapists – we are all in the business of care.

I thought that the fantastic games makers from the 2012 Olympics were going to be the inspiration for a new breed of volunteer within the NHS. People who could take care of the little things that mean so much while the clinically qualified spend more time on medical care and treatment. An example of this would be a cheery person at the ward reception who could answer relative’s questions such as ‘when will the doctor do his round or where is the hospital shop?’ Someone who can quickly find a nurse if one was needed. How often have you visited someone in hospital and no single qualified person can be found? At least a well-trained volunteer could go behind the scenes and ferret out anyone who was needed. We have heard of stories where the elderly are left with their meals out of reach or unaided even though they can’t pick up a fork. How lovely to have the equivalent of a meals on wheels type kindly soul to make sure patients eat and drink sufficiently and their personal needs are catered for.

 Caremakers? Great idea for carefully trained volunteers. Very different from Caregivers - all medically qualified people should be caregivers as a matter of routine.

 

Why do hospitals fail ?

 The Care Quality Commission (CGQ) have just announced that 17 NHS hospitals are included in a list of 26 providers failing to operate with safe staffing levels. London Ambulance Service is also included in the roll of shame.

http://www.bbc.co.uk/news/health-21002205
 

How do you define safe staffing levels? I have witnessed wards with plenty of staff but still failing to provide adequate care. Even more importantly – how do you define a failing hospital and why do hospitals ‘fail’? The Mid Staffs inquiry is still an open wound, reminding all concerned with healthcare of just how catastrophic the outcome of poor management and poor care can be.

The CQC has indicated that the facilities and services named in the list must ‘comply with its standards, and show how they were going to achieve this’

I must be among many who continue to be more than a little confused about to which tune a hospital must dance. The Health and Social Care Bill of 2012 strengthened Monitor’s role, defining the regulatory body’s main duty as ‘protect and promote the interests of people who use health care services by promoting the provision of services which is economic, efficient and effective, and maintains or improves the quality of services’. A classic sound bite that says everything and nothing. The document entitled ‘Introduction to Monitor’s future role’ continues… ‘our job as sector regulator will be to work with other bodies, notably the NHS Commissioning board, the Care quality Commission and NICE…’

There is an old saying which goes ‘he who pays the piper calls the tune’. But who is calling the tune for NHS hospitals? According to the House of Commons select committee, the CQC has ‘failed to grasp its primary role to ensure patient safety’

Everyone of course has their view of how care can be improved and the lack of clarity is further exacerbated by organisations such as the Royal College of Nursing. Last month Jane Cummings, Chief Nursing Officer ‘helpfully’ (in my opinion, not, actually) defined the 6 ‘values and behaviours’ to ensure good patient care– Care, Compassion, Commitment, Courage, Communication and Competence. A worthy and attractive list – but how can the six c’s be implemented and measured? Ms Cummings went on to say that patients are ‘more complex’ these days. No! Patients are not more complex! They are vulnerable human beings who need to put their trust in the clinicians and support staff who are treating them. Yes – healthcare is more complex, technology more advanced and expectations (quite rightly) higher. But patients are still just the same as they were in 1948 when the NHS started.

Back to failing hospitals. It is an uncomfortable truth that Hospitals need to be run like businesses – not necessarily from the profit perspective but certainly from a position of good management, good financial planning, positive culture and meeting the customer’s needs in a cost effective way. Why do businesses fail? Apart from start–ups where the initial idea and execution is flawed, there are four main reasons businesses go under.

1)   The financial modelling is wrong so it will always operate at a deficit. Poor cash flow will finally catch up with the business and bring it down. This can apply to Hospital Trusts

2)   The customer base dries up – either due to better or cheaper competitors or because there is no longer a requirement for the product or service (such as the recent demise of the photography retailer – Jessops. Online sales and good camera phones have changed the marketplace). I don’t think there is a danger of any hospital running out of patients although of course a facility can be over-bedded or the emphasis of services may not reflect local needs.

3)   Overtrading. The business supplies more services and products than they can profitably handle – back to cash flow. This is the equivalent of unsafe staffing levels – hospitals providing too many services with inadequate resources.

4)   Poor Leadership. Where the basics of the business are sound, but staff are underperforming, they are poorly managed and fail to deliver the required level and quality of service.

Do these all sound familiar? Of course they do. And talking about poor leadership and failure to deliver service – it is poor financial management, poor clinical leadership or poor operational leadership that can generate damaging lapses in care, quality and efficiency.

So whoever is paying, or monitoring, the piper – the tune must be the same. Strong leadership, measurable targets and tangible feedback (from patients and clinicians) is the best hope for the future of NHS hospitals.

Am I sounding a bit like a broken record?

Christmas 2012 - business as usual?

So how was it for you? I hope the festivities went well and you had a happy time with friends and/or family. My day started well – just the way I like it – some peace and quiet before the hoards arrived. The halls were decked, table was looking beautiful – fitting of any stylish home magazine, the log fire burning, carols playing, turkey safely nestling in the oven as I prepared the vegetables.

And then disaster struck. Careless as ever, and not concentrating on the task - and sharp knife - in hand, I managed to gauge a deep wound between my thumb and forefinger. Ow! And then the blood started to flow. And flow. And flow some more. As various scenarios played in my mind, typically more worried about the mountains of food that threatened to spoil rather than the injury temporarily slowing me down, I suddenly realised that wasn’t sure what to do next. I knew this wasn’t a 999 (or on the US, 911) job. My life wasn’t hanging in the balance, but I did have an injury that may need medical attention. Should I go to casualty (emergency room)? I seemed to remember that my local Accident and Emergency unit was closed and I thought I knew where the nearest one was. But I also had a vague recollection of a leaflet coming through my letterbox mentioning a minor injuries centre that had recently been opened. But where was it? Was it open on bank holidays? Should I ring NHS direct – the free health information line? But where was the  number for that? Or how about my GP out of hours service? Where was that damned leaflet?

Luckily by the time all options had been fairly unsuccessfully explored, vast amounts of kitchen roll and pressure stemmed the flow and the mini crisis over.

But now as I reflect on these events on Boxing Day I realise several points. Yes, I must be careful with sharp implements. But as importantly – how come a healthcare geek like moi, who professes to live and breathe the business of health – failed so miserably to understand my local health services? Some quick research on line demonstrated that it is easier to find out where to recycle my Christmas tree (2 clicks) than to find out where to go with a bad cut (7 clicks and to be honest I’m still not clear and I still don’t know if it’s open 24/7). One thing is clear – the NHS needs to up its game on the information stakes. Minor injuries services are only effective if people know how to access them.

One thing I didn’t have to worry about was ’where’s my credit card? will my insurance cover the bill?’ I knew that if I needed it and once I could find it, the treatment would be available at no direct cost. The NHS is still ‘free at the point of delivery’ and this is something we should continue to cherish as another stressful year in healthcare draws to a close. Some things never change, the concept is still great, the majority of services excellent but stratgey and clarity still lacking.

And the leaflet? I found it wedged between two books ‘Excel for Dummies’ and ‘Communicating Effectively’. Go figure….

 

Pat on the back for the Aussies and their anti-smoking initiative

Australia and Australians are a bit like marmite or republicans – you either love ‘em or hate ‘em. I am firmly in the middle – admiring their weather, their positive attitude, their sportsmen and their wide open spaces but not so keen on the fact that my step daughter has been lured to sunnier climes and now resides in Brisbane.

But this weekend I salute the Australian government and their health ministry in sticking to their guns with their anti-smoking strategy. Australia is the first country to make it compulsory, by law, to sell cigarettes in plain packaging. Except it’s not actually plain packaging – the lethal drugs are now being sold in packs emblazoned with gory pictures representing the various diseases caused by smoking. A supermarket’s cigarette cabinet down under now looks like the horror section of a DVD rental store. Manufacturers have no choice but to place these graphic images on their merchandise and they have no choice of colour for their packs either – they must be green. The only nod to brand is the ‘brand variant’ being listed in small print at the bottom of the front of the pack.

Will this work and should a country seek to restrict industry in this way? In my opinion the answer to both is yes.

The tobacco industry is vehemently against this initiative, saying that it won’t work and will increase tobacco smuggling, forcing them to decrease their prices in order to be more competitive, hence leading to increased smoking. Mmm – a rather tenuous argument methinks. Of course they are against this move because it is bound to have a detrimental effect on the glamour associated with smoking by the young. Maybe there is an odd approach to smoking in Australia. My step daughter has told me how surprised she is that many of her peers, mainly young(ish) housewives smoke – usually in secret – to the extent that they wear rubber gloves when they nip outside for a quick fag so there will be no tell-tale marks on their fingers – bizarre!

I suspect that the immortal youth who already smoke will mentally distance themselves from the upsetting images on the packs, believing that such health nightmares could not happen to them. But maybe the horror pics will stop the next generation from starting in the first place – it’s got to be worth a try.

The pictures on packs in the UK do have some effect – a young friend of mine who used to smoke said he was tempted to ask for a pack not by brand but instead he would try to pick the pack with the least upsetting picture! I wonder in the future whether Australian smokers will ask for ‘the pack with the rotting teeth and ulcerated mouth’ rather than ‘the one showing a young women in an oxygen mask’.

It will be very, very interesting to see if this bold move makes any difference in the number of cigarette packs sold in Australia, and hopefully a long term study will prove that this has gone some way in reducing the number of smokers in the next generation. If this does work, and Australia reach the targeted reduction in smokers from 16% of the population in 2007 to less than 10% by 2018, then here in the UK we should take note of hard evidence and follow their lead.

And to the pro-smoking lobby and accusers of a ‘nanny state’ regime I have one thing to say – carry on smoking if you must, but don’t expect anyone to make it easy for your peers, or more importantly your children, to take up this lethal habit.

 

Whither procurement?

Or should I say wither procurement?

It was always going to happen – those ‘I told you so moments’ as top down NHS restructure led to cracks in the system. Alas, however well-meaning Andrew Lansley’s Healthbill was, the execution and interpretation of the changes were always going to lead to trouble as the NHS struggles to achieve savings of £20bn over the next four years.

A good example is procurement. As I witness changes in procurement strategy and behaviour I can’t help thinking of that hilarious scene in the iconic 60’s movie, The Italian Job. The incompetent would-be villains have a practice run to open a bullion van but overdo it with the explosives. As the van is blasted to smithereens, the head honcho says  “You're only supposed to blow the bloody doors off!"

Some trusts and Clinical Commissioning Groups (CGGs) are viewing procurement as a blunt instrument of torture, aiming at sweeping cost cuts without considering the implications of squeezing suppliers till they, at best, bleed, at worst, expire. I was passed a document recently from a Hospital Trust advising a supplier that ‘in addition to and savings initiatives driven by our procurement department, we are also applying a 2% settlement discount on all invoices presented during 2012/13’.Take note – this isn’t an early payment settlement, this is basically chopping 2% of the bill, and it’s quite likely that the bill will be paid late too. Hardly ethical practice. This supplier, like many others, had also been advised that there will be an additional 5% reduction in terms or no deal. Like many independent suppliers working with the public sector, this supplier’s margins are virtually zero so what can they do? Operating in a specialist clinical device sector, this company could go out of business and the NHS will lose access to some exceptional intellectual property and equipment vital to enhance some patients’ quality of life.

The procurement mantra should be ‘value’, not ‘cheap’, and short term savings are not necessarily translated into long term value.

Effective procurement needs a robust strategy, experienced operatives and clear tender process. The ‘various procurement organisations and initiatives’ (to quote a recent procurement conference promotional literature) do not generate the clarity needed. It is highly time-consuming and expensive to complete an NHS tender process and if each Trust or CGG uses a different document, suppliers are at risk of re-inventing the wheel with alarming regularity.

Speaking of experienced operatives, a quick glance of the interim job ads display an air of desperation. As the disassembled Primary Care Trusts created an unprecedented brain drain, the newly formed procurement teams are, in some cases, sadly lacking essential expertise. Here is one of many of those ads:

I am urgently seeking a Commissioning Project Manager for a 4 month contract in London. Essential skills include:
- NHS experience
- Masters degree or equivalent managerial level experience or qualification
- An understanding of the NHS policy framework
- Understanding of procurement and contracting rules in the NHS
- Experience of working successfully with clinicians particularly GPs

The ad continued with other worthy attributes such as stakeholder engagement, bla bla.

But where would such a candidate have gained such experience? In the NHS. So this organisation will either be re-employing someone who was made redundant earlier or they will be pinching an expert from another procurement body. Same old same old.

No-one can argue that savings must be made for the NHS to remain a sustainable, free to all, health service. But efficiency savings should be as the name suggests – efficient. Working smart, not just cheap, is the way forward.

Liverpool Care Pathway – one man’s meat is another man’s poison.

This is a debate this isn’t going away any time soon. And now the government is including a change to the NHS Constitution which will, in effect, change the law regarding the way that the Liverpool Care Pathway can be applied.

The suggestion is that relatives must be involved in decisions regarding ‘end of life’ care for terminally ill patients. I have a strong personal view about this having nursed my beloved husband through to what I would describe as a ‘good death’. Peaceful, without pain and in my arms. You could say that we were fortunate, as a pharmacist and stroppy mare, I was intimately involved with every decision about pain relief and care and no, the Liverpool Care Pathway was not included.

The regime is designed to relieve suffering and of course includes pain relief but controversially may involve the withdrawal of food and water. This sounds horrific but must be viewed in the context of a terminally ill individual who may be incapable of taking on board sustenance.

As the news of this proposed change in the NHS constitution was announced I listened to an interesting radio debate on the subject. Two callers, both recently bereaved, spoke with passion and knowledge about their recent experiences of supporting a much loved relative through their final hours, one with a highly positive view of the LCP, and one vehemently against. They both spoke angrily about ‘dying with dignity’ – a phrase that makes my hackles rise at every mention. How can anyone describe what dignity means? Surely a ‘good death’ – i.e. – at peace, in comfort and hopefully without pain – is what we should want.

I remember a recent news item about an old lady suffering from pneumonia. The nursing home advised her niece that there was little chance of recovery and they would adopt the LCP to ‘ease her passing’. The niece was having none of it and knowing what a feisty lady her aunt is, insisted that antibiotics should continue and there should be no talk of dying. Two years later, the sprightly old dear was enjoying a game of scrabble as she celebrated her 90^th birthday.

Discussing care of a relative who is unable to speak for themselves doesn’t always work in the patient’s favour. There is a real risk (and no doubt plenty of examples can be found) where an elderly or infirm individual may be seen as a burden and a terminal care pathway seen as a blessed relief, not for the patient, but for their beneficiaries. Harsh but true.

So to get off the fence, what is my view of the LCP and a change in the constitution? Care pathways for terminally ill patients are normally designed specifically for that patient, discussed with the patient, or if that’s not possible, with their relatives. The LCP is one solution in a complex tool box full of options for a clinician to do their best for the patient. To focus this debate on only one method of terminal care is unhelpful and confusing.

As the former secretary of state for health famously kept saying – ‘nothing about me without me’ – in a perfect world, these life changing, and possibly life ending, decisions must be made with an informed balance. Doctors, nurses and therapists can only do what they believe to be best for an individual state of circumstances. The views of a patient and/or relative must be sought and the discussion must be recorded on the patient’s notes along with the way forward which has been agreed.

This will protect not only patients, but their clinicians too.