This is close to an anniversary for me. I arrived in Dumfries as the Acute Trust Finance Director on Saturday 15 May 1999, the same day that my home side Swansea RFC were hammering local rivals Llanelli in the Welsh cup final. This was not supposed to happen. Not the coming to Dumfries part; that has been largely wonderful from my perspective. Nor the rugby part, as Swansea’s win was as predictable as it was crushing. No, it’s the Finance Director bit that still puzzles me.
I never set out to be an accountant. I vaguely remember falling in with the wrong crowd after University and recall trying to explain things awkwardly to my mum and dad, but still feel a sense of shock that a few years later I’d become qualified. My results came in the post on the day that Wales lost to England in Cardiff for the first time for 28 years. With the new letters behind my name I was able to understand that, in both gross and net terms, this was a bad day.
What I’d intended to do, instead of this frankly unfathomable debits and credits business, was to work in something that built on my interest in history. By far the best teacher at my school in the Swansea valley was a gruff, chain smoking Cumbrian called Mr Fielding. He understood the power of ideas (and debate over ideas) in enthusing teenage minds all too ready to drift to other areas of interest. Amazingly, Mr Fielding could somehow generate a classroom of vibrant, sometimes almost violent, argument about the role of Thomas Paine in inciting revolutions or of Thomas Hobbes in averting them. For me, history was as cool as studying could get and I chose school exams and degree accordingly.
I’ve recently started wondering if my old interest isn’t coming back to haunt me. As Chief Executive, I have an appointment letter from the Cabinet Secretary setting out my role as the NHS Board’s “Accountable Officer”; essentially, this says that I will be held responsible for all of the actions and decisions of our local NHS. This is enough to give some sleepless nights at best of times but, at the moment, makes me particularly thoughtful. I’m thoughtful because the decisions that we make over the nature of health and social care in the next year or so will shape our population’s services for generations to come. The quality of our decision making will reverberate through this region’s future in a way that should give us all pause for reflection.
Take a tiny element of the acute services redesign project… We’ve recently made a final decision on the number of variable pressure isolation rooms in the new facility. DGRI currently has none that meet the exacting new technical standards and we’ve attempted to predict future demand (if any) for these specialist facilities. We’ve taken (often conflicting) advice, weighed up costs and impact on ward layouts and made a decision that four is the appropriate number. Now if clinical demands stay broadly as they are today, four is too many and our successors (as they arrive in their jetpacks?) will bemoan the waste of space and reduced flexibility of ward layouts. If, for example, extreme drug resistant TB becomes the norm or exotic new viruses appear, we have built too few and our successors (all cycling in?) will curse our lack of foresight – though I think they’ll be pretty relieved about the outcome of the 100% single rooms debate! Maybe the answer could be determined in a Swiss laboratory where a young researcher is on the cusp of a breakthrough to create the next generation of antibiotics; or perhaps she’ll get a text from her mates and go down the pub instead….
And remember, this is a small piece in the jigsaw of designing a facility that will be operational into the 2070s. Every one of our decisions (on bed numbers, ward layouts, electronic record management, clinical adjacencies etc…) presents similar uncertainties. I want everyone involved in this project, from staff giving up their time to attend yet another meeting, to Board members ratifying business cases, to be aware of our enormous historical responsibility in making the best decisions we possibly can.
At the same time as we’re determining the shape of the region’s acute services, we’re trying to reinvent our relationship with adult social care. Our aim is to try and operate essentially as one organisation that delivers the highest quality health and social care as close to people’s homes and communities as possible. It will be a hugely complex process, but one that is essential if we’re to meet future demographic and financial challenges. No UK health system can at the moment demonstrate such a fully aligned model of care, so we’re at the cutting edge of high risk innovation. Just where an accountable officer loves to be…
The third great change that we will need to deliver concerns our relationship with our patients and their carers. Bevan invented the NHS (or G.I.G. in the original Welsh) as a near monopoly provider of care and treatment. The traditional critique of monopolies is that they can become unresponsive to clients and slow to innovate; I think our clinical teams often make a nonsense of this view. Over the last few years in particular, we’ve seen an explosion of redesign and innovation that has reduced waits, introduced new approaches to treatment and made care measurably safer.
But this on its own is no longer sufficient. The challenge now is to bring the same scale of innovation and quality improvement to every aspect of our interactions with patients and their families or carers. This is partly to meet the big social changes of history; the patient in front of the healthcare professional in 2013 has different expectations from those of their 1948 counterpart (and we can guess that their 2050s successors will have higher requirements still). But it is much more about simply doing what is right, about providing the same ‘person centred’ care that we would want for us or for our families.
Of all the once-in-a-generation changes that we’re engaged in at the moment, this one is the most important and the most difficult. There were over 46,000 attendances at our A&Es last year, around 80,000 Outpatient appointments, over 20,000 hospital stays and hundreds of thousands of primary and community care interactions with patients in the community. The challenge of making each of these contacts of the highest value to the individual and family involved is enormous. But without that aspiration, I think the new hospital and integrated health and social care developments will not themselves deliver what our population needs and deserves.
So these should be our ambitions; to bequeath the coming generations with a fit for future acute hospital at the heart of an integrated health and social care service, where every contact with a patient or their carers is of the standard that we would want for our families. And if we can pull this off, then I think we’ll have made a decent bit of history.
Jeff Ace is the Chief Executive of Dumfries and Galloway Health Board
Next weeks blog will be by Dr Angus Cameron Medical Director for Dumfries and Galloway Health Board