Island reflections by Heather Currie

Holidays are for fun, relaxation, recharging the batteries, catching up, all things good. But holidays also give time to think and reflect and often holiday situations trigger a thought which may have relevance to a work situation. I think that’s ok, I don’t think I’m pathologically workaholic. I enjoy having time to reflect, whether that be on holiday or other.

heather-jettyA recent holiday in the beautiful west coast, triggered reflection on how we respond to patient’s needs, and perhaps how we could do better.

On the west coast of Mull is a ferry which goes to the tiny island of Ulva. While waiting to take a boat trip out to the Treshnish Isles (home of a huge colony of wonderful puffins), I noticed the sign indicating how to summon the ferry. No regular routine service, just a board with a moveable cover. Move the cover, red board shows, ferryman on Ulva sees red board, ferry sets out. Simples.. Ferry there when needed and when summoned. Receptive and responsive. It made me think whether or not we are receptive and responsive to our patients’ needs and what about the needs of the relatives?  A few examples make me think perhaps not enough?

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In recent times my mother in law sadly suffered from a stroke and was in an acute hospital for several months before being transferred to a Rehab unit and subsequently a nursing home. Being a patient is always a humbling and learning experience, as is being a relative and visitor of a patient. On one visit I was concerned that her finger nails were quite long and dirty. “Mum” could not speak at this stage but since she was always very particular about her appearance, I knew that this would cause her distress and asked the nurse in charge if it was at all possible, please please, thank-you so much…(it felt like asking for anything was a major challenge) could her nails be cut. To my surprise and disappointment, I was told that this was not possible since only two nurses on the ward had had the “training” and when they were on duty it was unlikely that they would have time. Receptive and responsive or too rigidly bound up in rules and protocols of questionable evidence base that basic needs are not met? Thereafter we took it upon ourselves to cut the nails ourselves!

I was very reassured on return to DGRI that this would not happen here and strongly believe that we are more receptive and responsive, but could we do better?

Recently, one of our gynaecology patients who had been diagnosed with a terminal condition was moved between wards four times as her condition deteriorated. As long as her medical and nursing needs were being met, was it fair on her at this sad stage to have so many moves? Did we really think about what was best for her and her family and were we receptive to their needs?

In outpatients, how often do we ask patients to return for a “routine” appointment when they may not need to be seen in six months time, but have problems at a later date? Could we instead be able to respond to their needs and see them or even make telephone contact when really needed?

An elderly gentleman understandably complained because he spent a whole day travelling from the west of the region to Dumfries by patient transport, for a ten minute outpatient appointment to be given the result of a scan. In his own words, “he was not told anything that could not have been told by telephone”.

What routine investigations do we carry out that are of limited clinical benefit, often subjecting patients to yet further unnecessary investigations because of slight irrelevant abnormalities?

When questioning our practice, let’s also be prepared to be curious about that of others in hospitals to which we refer—recently a patient was referred to Glasgow for a gynaecological procedure. The procedure went well but the patient subsequently contacted me concerned that she had been asked to return to Glasgow for a follow up discussion. She wondered if a phone call would be possible in view of the huge inconvenience that this appointment would cause. I wrote to the consultant and asked if this would be possible. His rapid response was enlightening and reassuring: he had always brought patients back to a clinic as routine practice and never considered an alternative. He promised that from then on he would offer all such patients a telephone follow up instead.

Let’s use common sense and be prepared to challenge and bend the rules. Remember the ferry. While we do not have a “ferryman” waiting to respond at all times, we could consider the 4 “Rs”and be –

Responsive not Rigid,

Receptive not Routine.

Heather Currie is an Associate Specialist Gynaecologist and Clinical Director for Women and Sexual Health at NHS Dumfries & Galloway 

 

 

 

 

 

 

 

Speaking out: A Student’s Perspective by Ren Forteath

I was recently asked to speak at a conference organised by our consultant midwife on the topic of Person Centred Care. She wanted to hear thoughts on the topic of ‘Speaking Out’ from a variety of perspectives and asked me as a midwifery student on placement. I was delighted to be asked to present, perhaps the first indication that speaking out may not be something I find overly daunting! Having a background in amateur dramatics gives me an advantage when it comes to assessed presentations or even leading parentcraft classes when on community placement. The same could not be said of everyone in my class. Even approaching the end of our final year, many of my peers quake with nerves when asked to give a presentation. This fact caused me to consider ‘speaking out’ not only from my point of view, but from that of other students who might be younger and less outgoing than myself. (As a mature student I have quite a few years on some of my class!) The topic encompasses a variety of scenarios, and I tried to think of personal experiences that illustrated my feelings.

On a shift to shift basis we speak to women we care for, other students, midwives and doctors – and sometimes that is no less nerve racking than giving a presentation! Naturally as we progress through our course we become more confident, we gain more knowledge and our comfort zone broadens. But inside there is always a kernel of fear that we’ll say the wrong thing – or not say the right thing. Personally, I’ve had a couple of experiences that spring to mind.

In first year I was with a woman who had written in her birth plan that if things didn’t go as expected and she needed help, she would rather have a kiwi delivery than forceps. I thought no more about it until we reached that point. The reg was called in to do an assisted delivery – and he immediately went for forceps. The woman was fairly out of it on diamorphine and becoming distressed. She couldn’t speak up for herself.  So, I swallowed my fear, took a deep breath and said…’eep’. Then I took another deep breath and said “Doctor, um , she’d really prefer the kiwi, if you don’t mind, please, thank you very much”.  And he did it! She got her kiwi delivery and she was so happy. And I was absolutely on top of this world! It was so exhilarating. I had been an advocate for my woman. I had spoken up to a doctor – and he hadn’t bitten my head off! And then second year happened.

I was on shift and we heard an emergency buzzer, so we all ran to room 7: and it was a shoulder dystocia skills drill. Well, really, what were we expecting? There was only one woman in labour that day and she was in room 3! So one person took charge and started working through the HELPERR mnemonic and I thought “hey, I remember this, I know this stuff”. Then the consultant walked in, made a quick assessment of the situation and said “O.K. with a little fundal pressure, I think we can get this baby delivered.” Everyone else just looked at each other and I was thinking “that’s not right  – I know that’s not right – it’s suprapubic pressure.” And then someone suggested doing exactly that but the consultant said again “Come on now,  a bit of fundal pressure! Please, will someone put their hand on the fundus?” And I thought “it’s not right, is it?” And as if of its own accord, my hand started to move. Well, his voice was just so hypnotically consultanty. Then my mentor shot me such a daggers glance that, seriously, if looks could kill, that midwife would be in prison today! My hand shot back down, but not before at least two other people had seen it. So that sparked a useful discussion on listening to your inner voice and always speaking up, diplomatically, if your knowledge of evidence based practice tells you something is wrong. It also sparked a debate on whether it’s appropriate to use ‘making the student feel like a prize turnip’ as a teaching technique. And I wished the floor would open up and swallow me whole.

And now I’m in third year. There is light at the end of the tunnel and I’m beginning to believe it is not an oncoming train. I still have a lot to learn but I’m really starting to feel like part of the team. I suggest things and people listen. I coach women through fear and panic to relief and joy. I hold my own.

A large part of how easy or difficult it is to speak out is the people you are surrounded by. In my clinical area we have great teams, both in hospital and on the community. My classmates who have been here on rural placement always say how much they enjoy it; the working environment, the attitude, the team. People are encouraging, patient, willing to listen and keen to teach. They are inclusive and welcoming. I have rarely been berated for starting to do something the way I was shown at Uni rather than the way the midwife I was working with that day would normally do it. Not never, unfortunately, but rarely and never by a mentor.

Having my student placements there has made my own experience a hugely positive one and has equipped me to find my voice and to know how and when to use it. I know that many in my class feel the same way about their mentors in their own areas. Speaking up and speaking out are still not always easy…. but we’re learning, and as we complete our degree programmes and step out into the wards as shiny new midwives, we will find the strength to speak for our women, and for ourselves.

  • Trust your learning – if your evidence base tells you it isn’t right, say something (even to a consultant)
  • You are her advocate – if she can’t speak for herself, it’s your job to speak for her
  • Be diplomatic – just because you need to say it, that doesn’t mean you have to upset anyone
  • Find your voice – you can have a positive impact by saying the right thing at the right time

Ren Forteath is a Student Midwife

Do you want free dental treatment? by Kim Jakobsen

#hellomynameis Kim and I am encouraging the people of Dumfries to consider self referral to a dental student at Dumfries Dental Centre for free dental treatment.

There has been a dramatic improvement in access to NHS dental care in the region over the last 6-8 years. The Dumfries Dental Centre opened January 2008 to provide an outreach / training programme for student dentists and student dental therapists, aimed at supporting the future growth of these professionals across Scotland, while continuing to provide secondary care dental services, emergency dental services and routine NHS dental services which moved from Nithbank. The plan was to provide additional access to NHS dental registration at the centre, but on opening, access to Independent Dental Contractor practices for NHS dental registration had increased. Following a review of the Health Board’s managed dental service, recognising the increased access available for patients to NHS dental registration, routine NHS dental services at Dumfries Dental Centre were withdrawn in 2015.

With the goal of improving oral health while modernising dental care, prevention has played a key role in the dental care being provided by dental professionals for some time. This means that patients who are registered and regularly seeing a dentist, dental therapist, dental hygienist or extended duty dental nurse are getting orally fit.

This combination of increased access to NHS dental registration and patients getting orally fit is great news but it does mean finding suitable patients who require routine treatment to support our dental student outreach programme is becoming more challenging each year.

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image2Outreach programme aims

David J. Watson, Senior Clinical University Teacher at Glasgow Dental Hospital and School explains that ‘The Outreach experience is intended to enable the student who has already attained basic competence in a range of areas to grasp the concept of the provision of holistic oral health care in the primary care setting and to gain an appreciation of integrated multisectoral involvement in health care delivery. The aim of the entire experience is to aid transition from the dental school to the practice environment by replicating the primary care experience as closely as possible.’

Who makes a suitable patient?

A broad base of patients with differing needs is desirable for the Outreach programme. Patients receiving emergency dental care provision and who are unregistered with a GDP may happily return for a course of treatment. Patients who self-refer can be screened for suitability at the initial examination, as can other healthcare professional referrals.’

Please note the following;

Appointments can last 1-2 hours and sometimes a bit longer.
Patients won’t always be able to see the same dental student, as they attend Dumfries Dental Centre from Glasgow Dental Hospital and School one week at a time.
Patients should have realistic treatment expectations.
Patients who are, for example, extremely nervous of dental treatment or requiring specialist intervention should be suitably referred.
Patients with special care requirements would be assessed for their ability to cope with routine dental care.
Patients with health preclusions would not be excluded automatically unless they would impede routine treatment provision or necessitate specialist intervention.

How and where do we find patients for our students?

The answer is from You. Please spread the word about our student dental outreach programme. Come and see us for yourself if you are unsure about us and/or happy to refer people to us. The facilities at the Dumfries Dental Centre are quite something. The staff and the students are all friendly and good at what they do; believe me they get lots of praise from their patients.

Are you interested yet?  I really hope you are.

Further information and self referral application form is available at: http://www.nhsdg.scot.nhs.uk/Departments_and_Services/Dental_Services/Dental_Student

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In summary;

Dumfries Dental Centre has a student dental outreach programme operating August to May.
The student dental outreach programme needs dental patients requiring routine dental treatment; this could be you, your family, a friend, your neighbour or a member of the public that you come into contact with.
Student dentists are in their final fifth year of studies.
Student dentists are supervised which includes their work being checked.
If accepted to the programme, treatment is free from a student.

Kim Jakobsen is Dental Services Manager for the Public Dental Service

Clinical Efficiency by Ewan Bell

In a previous blog (“Prioritisation in NHS Scotland” – November 2015), I opined that ‘we can’t continue to provide the current range of interventions and services, if we want a sustainable NHS for the future.’ In other words we really need ‘to start debating and defining the essentials of health-care and what can we pull back from’. I had numerous comments and emails from colleagues; the majority supportive of my view. Since then there have been several blogs, including Chris Isles (“Time to Prepare for our new Hospital” – December 2015), Catherine Calderwood (“A Message from the CMO” – February 2016) and Anne Marshall (“Rights without Responsibility – Where are we Going?” – August 2016). These, in some way, have all informed that debate.

Chris believes ‘that the 5th largest economy in the world could afford to provide high quality emergency care as well as batteries for hearing aids and palliative chemotherapy for the frail elderly (if that is what they really want), but if I am wrong then surely the batteries and the chemo must go’.

I think he is wrong and here’s why. Year on year from 1997 to 2013, the UK has spent more and more on healthcare. Below is the most up-to-date data I could find from the Office of National Statistics.

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Currently (2016-17) the UK spends approximately 18% of its overall budget on healthcare – about £143 billion (total UK expenditure is £784 billion). If our answer to the increasing demand on our current health service is to keep increasing the amount of money that we spend on it by the same factor (x2.97) every 16 years, then by 2033 we’ll be spending approximately 52% of our country’s overall budget on the NHS, squeezing out spending on education, pensions, social security and defence. Now I know that Economists will laugh at the simplicity of this argument (fair cop I say) as I haven’t taken into account rising GDP (if it does post-Brexit), but my point is that there is never going to be enough financial resource in the NHS to meet an ever increasing demand (and nor has there ever been).

The recent Chief Medical Officer’s Annual report ‘Realistic Medicine’ and the National Clinical Strategy (NCS) 2016 raise several fundamental questions, which include:

How can we further reduce the burden and harm that patient’s experience from over-investigation and over-treatment?
How can we reduce unwarranted variation in clinical practice to achieve optimal outcomes for patients?
How can we ensure value for public money and prevent waste?

The context to these questions is described in the NCS:

“Value-based healthcare is an established approach to improving healthcare systems across the world – the central argument is that higher value healthcare is not necessarily provided by higher inputs. What matters more is that care is provided early in disease to prevent progression (avoiding the added patient burden of more intensive interventions), it is provided safely to avoid harm, it is proportionate to the patient’s needs (avoiding the waste of providing outcomes that are not relevant to the patient), it is provided consistently and reliably (avoiding unwarranted variation).”

“Over-treatment, wasteful treatment and variation is a broad subject, and an important one. It is important that it is addressed in Scotland so that we can be more confident that the use of resources is targeted to producing outcomes that matter to patients.”

So the national conversation has started. How do we ensure value for public money? And how can we be more confident that the use of resources is targeted to producing outcomes that matter to patients?

Do we systematically, and with rigour, evaluate and rank the clinical value of new drugs, new devices, new clinical guidelines or new procedures? No we don’t, but we should and if we are going to invest in a new intervention with significant clinical value, how are we going to afford it?

Part of the solution might be for each of us to start looking at our own clinical practice in terms of over-treatment, wasteful treatment and variation. Does our rate of intervention vary significantly with the national mean, and if so, is this variation warranted or unwarranted? Is there any part of our clinical practice that we do, because it’s always been done this way, but actually it really doesn’t benefit the patient?

There is already a lot of good work going on in Dumfries and Galloway looking at waste and variation. The Surgical team, led by JK Apollos and Stuart Whitelaw have recently been looking at the clinical value (there’s very little) of routinely sending sebaceous cysts and lipomas to Pathology. What about gall bladders? Heather Currie, Ranjit Thomas and Kim Heathcote and other clinicians meet regularly (the lab demand-optimisation group) to put in place measures to reduce wasteful and thoughtless laboratory requesting (do you know that the blood sciences lab processed 40,000 thyroid function tests last year)? This is not just about money. Over-requesting of lab tests can often result in the clinical pursuit of minor, insignificant abnormalities, which can lead to over-investigation of patients and on occasions harm.

There are lots of opportunities here to improve patient care and start to tackle some of the issues raised by the CMO and NCS. I have been asked to start looking at waste and unwarranted variation here in Dumfries and Galloway and hope that you will help by considering the real clinical value of all that you do and identifying clinical waste.

Ewan Bell is a Consultant Biochemist and is AMD for Clinical Efficiency

Cutting the Sugar…. by Fiona Green

Over the last 2 years NHS DG have been offering a structured programme of work experience to young people in their final years at school thinking about a career in medicine. This has been very well received by the young people who attend and the success of the programme is largely down to excellent organisation and communication skills of Anne-Marie Coxon and her team in the education centre who arrange tasters in various areas of medicine including medical admissions, theatre, surgery and A&E along with some time with me in the diabetes centre

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Linocut by Hugh Bryden Crichton Hall- home to the Dumfries Galloway Diabetes centre

As a clinician it has been really interesting to spend time with these young people who have yet to develop preconceived ideas about healthcare and for me to try and understand what it is that excites them about spending a lifetime in medicine and to try and remember what it was that motivated me to apply for medicine and ultimately what made me move into Diabetes and Endocrinology.

For those of you who know me you will have heard me say that it is diabetes that excites me rather than the rare and esoteric conditions that I deal with in the endocrine service but I recognise that despite my real enthusiasm and commitment to improving care in diabetes that when these young work experience students come to diabetes clinic I sometimes find myself apologising to them that I don’t have any exciting procedures to show them, or new diagnoses to make; in fact in diabetes clinic I rarely examine people and I spend my time just listening to things that seem unrelated to sugar levels and talking…..

Just Listening and Talking…

The fact that I feel the need to apologise about the nature of diabetes clinic being  “just listening and talking” has made me realise  how little value we as hospital healthcare professionals place on these core skills that we all use every day. We are required to do mandatory training in many important areas such managing the deteriorating patient, infection control, awareness and fairness to name a few- yet it is possible for a healthcare professional to go through their in working career without any update, assessment or post graduate training in the core communication skills that we use every day. This lack of post graduate training in clinical communication skills is particularly apparent in the acute hospital setting compared to our colleagues in general practice and psychiatry where advanced post graduate training in consultation skills is the norm. Despite the seemingly acute nature of a hospital environment many of us spend a large part of our working week in clinics working with people to try and improve their health and wellbeing but what are we doing to ensure that these interactions are effective and meet the patient’s agenda?  Do we find it easier and quicker to pursue our own agendas and default into education mode rather that hearing about what is really important?  Several research studies have shown that by exploring a person’s background, worries and their understanding of their condition can help to avoid unnecessary investigations or anxiety for the patient as well as reduce the strain on resources[i][ii]

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The success of the late Dr Kate Granger’s “Hello my name is …” movement and the “What Matters to Me” campaign show that in acute setting healthcare teams are beginning to contemplate a change to a more patient centred rather than the traditional paternalistic, didactic approach to our interactions with patients but this change is slow and these important initiatives are only an entry level to improving our communication with the people we see in clinic and reaching a shared agenda.

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Locally Jean Robson and her colleagues from psychology, human resources and other interested clinicians have recently worked hard to put together a directory of diverse courses and programmes which are delivered locally by NHS Dumfries and Galloway aimed at improving advanced communication skills including sessions on communication skills which allow individuals to film and review their performance in real life clinic setting (been there and done that -daunting but very helpful), communicating with people with existing communication difficulties, human factors training and sessions on communicating with colleagues in meetings to name a few

So, back to the title of “cutting the sugar”. The discovery of insulin almost 100 years ago is one of medicine’s most remarkable discoveries changing the outcomes for people diagnosed with type 1 immeasurably as the before and after pictures below poignantly demonstrate

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December 1922

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February 1923

 

 

 

 

 

 

 

 

 

“Child 3” before and 3 months after insulin treatment

There is of course a but; insulin is not a cure for type 1 diabetes just a treatment and Insulin treatment brings with it a huge burden for the person with type 1 diabetes- blood testing more than 4 times a day, injecting insulin at least 5 times a day, assessing the carbohydrate content of foods are all required to achieve the tight blood sugar targets required to maintain health and wellbeing. This all needs to be balanced against activity levels and avoidance of hypoglycaemia. People with diabetes can never have a day off.  They become experts in managing their blood sugar levels and this brings me to the “just listening and talking bit”. Listening to what’s important to people when I’m clinic seemed more time-consuming in the beginning but by encouraging this shared understanding I have come to recognise that almost universally people with type 1 diabetes want to be healthy and that they fully understand the importance of controlling blood glucose but what I also now appreciate more clearly is that there are many other things that get in the way of achieving this goal. Some of these barriers to change seem obvious e.g. fear of hypoglycaemia, fear of injections but others may take gentle probing to identify e.g. the young woman who removed her insulin pump because she had a new boyfriend who didn’t know she had diabetes, the young mum on her own putting her own health after the needs of her family. Through training, practice and reflection I have come to learn is that each person is different and whilst a particular solution may work for one person it might not work for the next and whilst the temptation is for me to offer the solutions that I think will work by practicing the skills I have learnt at various communication skills sessions I now recognise that solutions generated by the person with diabetes are far more likely to be successful that anything that I may suggest. Of course very few consultations are perfect and like every skill we use practice, reflection and additional training can help us to improve which is why I believe that consultation and communication skills shouldn’t be seen as just “the icing on the cake” but more of the “meat on the bones” of our daily work.

Dr Fiona Green is a Consultant in Diabetes and Endocrinology at NHS Dumfries and Galloway

[i] Heisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA (April 2002). “The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management”. J Gen Intern Med. 17 (4): 243–52. doi:10.1046/j.1525-1497.2002.

[ii] eisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA (April 2002). “The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management”. J Gen Intern Med. 17 (4): 243–52. doi:10.1046/j.1525-1497.2002.

Why wont MY ‘thing’ go viral? by Ros Gray

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Dreams are made when your great idea gets out there in this social world and goes viral. The very thought that thousands of people (likeminded as you) are looking at your good idea and thinking – “That’s a great idea, I could do that”
especially in our health and social care world when it isn’t necessarily the idea that’s new (although sometimes it is) but the ability to engage others to get them to follow your lead, for the benefit of patients and families.

So when things take off in this way, is it just good luck, or is there something we can learn? How does a good idea move from being MY great idea to something that a lot of other people want to do too?

In his New Yorker article ‘Slow ideas’ Gawande started my thinking on this topic (and a million other things!) when he discussed the evolution of surgical anaesthesia compared with the uptake of antiseptics to prevent sepsis. He described how the former spread almost worldwide in 7 years, the latter taking more than 30 years (and you might argue that the inability to clean our hands consistently even today means that we still haven’t cracked it).
It’s easy to imagine the difficulty undertaking any surgical procedure on a patient not anaesthetised (not least for the patient) – having your colleagues hold down the poor patient until such time as they (hopefully) passed out with the agony of the ordeal. Then you hear of an innovation where the patient inhales a gas and goes gently to sleep, allowing the procedure to be done with ease – a no brainer in terms of its likelihood to be adopted by others… and swiftly! The action of holding down the screaming patient and wrestling to undertake the procedure was clearly very personal and real for all those present.
However, the use of antiseptics to prevent an infection that the practitioner might never even see personally, leaves a lot to the imagination and limited personal cost, with the exception more latterly of professional reputation and in some quarters accreditation.
This situation was also exacerbated by the unpleasantness of the environment, where the practice of good antisepsis in the early days meant that theatres were gassed with antiseptics, hands scrubbed raw with early chemicals – all to prevent something that the practitioner might never witness… Perhaps, then, it’s easy to see why that adoption took longer than 30 years. Or is there more to it than that?

Gawande’s article goes much further and is very thought provoking but he fundamentally sets out how, if we want our ‘thing’ to be taken up by others at scale, then “…technology and incentive programs are not enough. “Diffusion is essentially a social process through which people talking to people spread an innovation,” wrote Everett Rogers, the great scholar of how new ideas are communicated and spread.”
He goes on to say that while our new social world can get the ideas out there
as Rogers showed, “…people follow the lead of other people they know and trust when they decide whether to take it up. Every change requires effort, and the decision to make that effort is a social process.”

I think these might be key concepts for us to consider with our personal improvement efforts. How hard do we make it to do the right thing?

Looking around at some other recent great ideas gone viral that I have become aware of – I thought it might be helpful for us to take a closer look at these and consider their spread from this perspective – I thank Delivering the Future Cohort 11 for their help with my developing thinking #DTFcohort11.

And also to consider how would the business world more broadly consider this issue?
Great marketers certainly start with two concepts that absolutely relate to our world and reflect Gawande’s thinking:
Know your audience
and
Make an emotional connection.

So looking at 3 examples of great ideas that have gone viral a little closer to home, can we identify the critical success factors that made them work so that we can apply that learning to our own work?

Case 1 – What matters to me

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Who Jennifer Rodgers @jenfrodgers Lead Nurse for Paediatrics NHS GG&C
What What Matters To Me (WMTM)

WMTM is a 3 step approach

1 Asking what matters

2 Listening to what matters

3 Doing what matters

Why “Clinicians, in turn, need to relinquish their role as the single, paternalistic authority and train to become more effective coaches or partners — learning, in other words, how to ask, ‘What matters to you?’ as well as ‘What is the matter?’”
Where Yorkhill Children’s Hospital Glasgow – global
When Last 4 years
How Originally Jens’ Quality and Safety Fellowship project, building on the concept of Lauren’s list in the USA; national and international presentations, Used the Model for Improvement as the improvement method. Started by asking one child to draw what mattered to them, and staff making every effort to include and react positively to this information –  now used routinely as part of the paediatric admission process. Spread includes other specialties such as the Care of Older People and those with Dementia.

Case 2 Hello my name is…

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Who The sadly very recently deceased Kate Granger (http://hellomynameis.org.uk @grangerkate) a young doctor battling at the time with terminal cancer, made observations about the human interactions she was struggling with at a very vulnerable time.
What Kate decided to start a campaign, primarily using social media initially, to encourage and remind healthcare staff about the importance of introductions in healthcare.
Why She made the stark observation that many staff looking after her did not introduce themselves before delivering her care. She felt it incredibly wrong that such a basic step in communication was missing. After ranting at her husband during one evening visiting time he encouraged her to “stop whinging and do something!”
Where NHS England – Global
When Last 3 years
How Twitter campaign initially – #hellomynameis has made over 1 billion impressions since its inception with an average of 6 tweets an hour.

Kate has left an incredible legacy with #hellomynameis that will continue to impact positively for patients.

Case 3 The Daily Mile

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Who Elaine Wylie – Headteacher (recently retired) St Ninian’s Primary School, Stirling

thedailymile.co.uk

What The aim of the Daily Mile is to improve the physical, emotional and social health and wellbeing of our children –regardless of age or personal circumstances.
Why It is a profoundly simple but effective concept, which any primary school or nursery can implement. Its impact can be transformational- improving not only the childrens’ fitness, but also their concentration levels, mood, behaviour and general wellbeing.
Where St Ninian’s Primary School, Stirling – global
When Last 3 years
How The Daily Mile takes place over just 15 minutes, with children averaging a mile each day.

Children run outside in the fresh air – and the weather is a benefit, not a barrier. 

There’s no set up, tidy up, or equipment required.

Children run in their uniforms so no kit or changing time is needed.

It’s social, non-competitive and fun.

It’s fully inclusive; every child succeeds, whatever their circumstances, age or ability.

Elaine demonstrated huge impact on eliminating obesity in her primary one class that had stated the Daily Mile in Nursery.

In each of the cases the idea started with one individual who had a simple, sensible, not necessarily unique idea, but certainly something that was a bit different from the status quo – perhaps even challenging and making the status quo uncomfortable.
Each leader had a degree of power and autonomy in their local context, for Kate this was as an informed patient, so some might argue her ability to influence would have been limited.
Each idea was simple and easy to try in different arenas.
Each was free or relatively low cost to implement, even at scale.
The impact on patients or children was obvious or in the course of early testing clearly demonstrated.
Each leader used social platforms as a spread mechanism.
In every case, the idea clearly feels like it was the right thing to do, or scandalous that it wasn’t happening routinely, something each of us would want to happen if we were the subjects in question. Perhaps even the standard we apply every day in our professional or personal lives and assume that everyone else does too.
So clear evidence to support Rodgers view that “Diffusion is essentially a social process through which people talking to people spread an innovation,” – Perhaps the easy access to social platforms in these cases made ‘people talking to people’ helped in these cases?
Each leader knew their audience and played to that strength – but also and perhaps most importantly in each case, the emotional connection is huge, but each from a very different perspective.
Is the emotional connection the critical success factor in these cases – and something we should consider carefully if we want our work to spread?
Which emotions might you tap in to when trying to engage folk in your great idea? Emotions described in pairs of polar opposites might give you some food for thought and a place to start with your great idea:
Joy or sadness
Anticipation or surprise
Fear or anger
Disgust or trust

You will have many more thoughts than time permits here, but I leave you with a thought of mine… perhaps we all have an opportunity to use a more considered approach to the scale up and spread of good intentions by learning from those that have done that well.
If not you, who? If not now, when?

image7

Simple checklist
How simple have I described my great idea – Have I got my 1-minute ‘elevator pitch’ worked out to easily influence others?
Does it feel the right thing to do?
Is it relatively cheap or free? If not who will fund the idea, now and then at scale?
Am I convinced that it isn’t happening to every patient/family every time, reliably? Do I have the data that proves that?
Do I have the power to influence, or if not, who do I have to get on board?
Do I have the data and story to describe how it works and how easy it is to adopt, including the impact?
What social platform for spread will I use?
Which emotions are triggered, or will I aim to tap in to, in order to engage people to want to do things differently?

Ros Gray recently retired from her post as National Lead for the Early Years Collaborative. Prior to that post she was Head of Patient Safety for Healthcare Improvement Scotland.

 

Rights without responsibility… where are we going? by Anne Marshall

“Man must cease attributing his problems to his environment, and learn again to exercise his will – his personal responsibility.”
Albert Einstein

 

‘It’s not my fault.’

‘It’s not fair.’

‘I want that.’

‘Why should they get that when I can’t?’

 

Responsibility – one of those words with which no one much wants to associate these days, but a word that I believe lies at the heart of the change that is essential to sustaining not just the NHS through the 21st century, but life beyond the 21st century.

In his blog Ewan Bell asked how the NHS should prioritise its services – what are the essentials and what should we be doing?

I think we need to turn that thinking round and look at it differently – from the point of view of ensuring that as we empower people we also expect them to be accountable and therefore responsible for the choices they make. . . so here’s a few thoughts and a lot of unanswered questions!

Anne 1The more society gives in terms of allowing individuals to renege on any personal responsibility and the more it protects them from the consequences of their actions and decisions the deeper into this complex and costly moral mire we sink.

So where do we start? Can we make the huge cultural shift required without some horrendous intervention such as war, which inevitably enforces change from selfish desire and want to more simple human need.

How do we teach people to take personal responsibility when they know they simply don’t have to take any because someone else will always pick up the pieces? How do we reduce escalating public expectation? The NHS cannot simply cut back on what it does while society as a whole continues to abandon all sense of personal responsibility; expects more and more to be done for it and litigious greed is ready to pounce on any perceived breach of human rights.

When prisoners win compensation for having the slop out their cells what hope is there of change? Don’t the rest of us have to clean our own toilets?

The fact that benefits are capped at £350 a week but someone on the minimum wage earns only £251.25 before deductions seems to be indicative of where we, as a society, are at. There are few or no consequences for failing to take responsibility. Add to this the fact that publically funded advice agencies actually complete forms for people and lie in order to get them certain benefits which they are neither entitled to nor need and you simply perpetuate perceived dependence, engendering more unnecessary demand and expenditure.

The problem is beautifully illustrated by the story of two students, aged 16 and 19 respectively, sharing a flat. The 16 year old gets her bursary and a job and puts some money aside for the summer months. Her wages fail to come through so she asks for support from the college hardship fund. She is entitled to nothing – because she has put a few pounds aside. The 19 year old blows all her bursary, litters the flat with takeaways and empty drink bottles, builds up a huge debt and gets handed out hundreds of pounds from the hardship fund . . .

Unfortunately the ending is not fair or just, or, more importantly in terms of the NHS, sustainable.

It reminds me of the story of the three little pigs and their houses built with straw, sticks and bricks. Two of the pigs learned their houses were not safe because they had to run for their lives from the big bad wolf and find shelter in the brick house built laboriously by their brother.

We have created a society where there is no big bad wolf – no consequences. We have created a society where people simply expect the state (be it NHS, benefits system, social services or whatever) to sort out all their problems and if they don’t many people either kick up a huge fuss, shout and scream until they get what they want or take on a lawyer.

Anne 2So how do we start to change things and find that balance between a society that takes care of its vulnerable and needy and yet engage differently with those who are outside of the vulnerable and needy group but still think they have the right to whatever they want at whatever cost – as long as it is not to their pocket or life style.

How do we start to embrace the massive moral and cultural shift needed from politicians down and ‘minorities demanding the same rights as majorities’ up? How do we deal with the human rights bill which in its purest form is an excellent and necessary thing but which is so open to interpretation and abuse that it forms a rod for our own backs?

Answers on the back of a postcard please. . . !

“When you blame others, you give up your power to change.”
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Anne Marshall is a Staff Nurse on the Renal Unit at NHS Dumfries and Galloway