Two Decades of Change by Jean Robson

20 years ago I joined the Charlotte Street practice, working in what had previously been the coal cellar of a large sandstone house. My room was dark, with bars on the windows, but spacious. The waiting room was immediately outside my door, but had no windows.
19 years ago we started trying to build new premises, had plans drawn up 4 times, but each hit a hurdle. 8 years ago a fire made our building unsafe – we were “temporarily” accommodated in Nithbank – the building had originally been a nursing home – a gentleman patient attending my surgery was reminded of the time he scaled the walls to ‘illegally’ enter the first floor room of one of the nurses! I did not need to put a radio on to avoid patients in the waiting room overhearing my conversations, but plumbing was noisy, when hands were washed in the next room I had to abort a chest auscultation, waiting rooms were extremely cramped, and wheelchair access impossible upstairs, and difficult downstairs. We were continually hot-desking, and staff were working in cramped noisy environments, not conducive to accurate and confidential work.

The process of building new premises has been long and fraught, endless meetings, negotiations, contracts, delays, moves aborted, then finally 6 months ago we moved to spacious light airy premises. Waiting rooms are big, which has a positive impact on consultations, patients seem more relaxed when they walk, or easily use their wheelchair to access my room. Staff have space to do their work, the whole team is able to meet in one room, the atmosphere is far less fraught than I recall in 20 years. Of course there are snagging problems to be resolved, but on the whole life is better! The time committed to ensuring that the building would work for us was time well spent, the developer has built surgeries before, but they had never built one for us.

The practice of medicine has also changed substantially over the last 20 years, the Quality and Outcomes framework (QOF) came in, which aims to ensure the quality of care for patients with chronic diseases, or risk factors. I feel that the QOF has brought more advantages than disadvantages, we have a responsibility to the population of patients as well as to the individual in front of us, and therefore need robust recall systems, and reminders about aspects of care. I disagree with those who suggest that QOF “makes us treat…..”; it does not, the only requirement is to consider appropriateness of a range of evidence based interventions. Unfortunately some of more recent QOF criteria have less of an evidence base; the national enhanced services can be insufficiently sensitive to local issues, and annual contract changes result in change fatigue, frustration and disengagement. These issues need to be worked on, but on the whole I feel the population of Dumfries and Galloway is provided with much more reliable monitoring and management of chronic disease than we managed 20 years ago.

In medical education changes have also resulted in difficulties and challenges. 20 years ago doctors in training applied for posts, joined a team, learned from their mentors (who knew them well by the end of their post), but could be exhausted after long hours on call, and might have no structure to their training; we have moved to a situation where EWTD limits the hours our trainees work, undoubtedly safer in terms of inadvertent errors; and trainees enter training programmes which aim to build competences required by a doctor at the end of training. The fragmentation of supervision required to meet EWTD rules makes it difficult for a supervisor to know his/her trainees’ strengths and weaknesses, so structured assessments are required. We are only just getting to grips with the assessments, and acknowledging that to do these well takes time and skill, but when done well can result in a comprehensive assessment, learning and development to ensure that our trained doctors of the future meet the needs of the population.

In summary my environment, our service, and our training has improved; but we need to go on working to make the most of our situations to ensure that identified priorities are addressed, and the needs of our patients and trainees are effectively met. However I can do that in a light airy, spacious, comfortable surgery; for the other half of my week I am grateful to Chris Isles for his help in ensuring that the developers understand the needs of OUR new education centre, so in 2017 I will feel comfortable in the new hospital.

Dr Jean Robson is a GP and Director of Medical Education NHS Dumfries and Galloway

Next weeks blog will be ‘Who is Molly Case?’ by Alice Wilson, Associate Director of Nursing, NHS Dumfries and Galloway

Don’t blog, never blog by @YeWeeStoater

I don’t blog, I never blog! By the time I get around to typing something legible I get distracted and the blog is neither finished or has become old news.  However, when I was asked by Dr Ken Donaldson to write a blog for the new Dumfries & Galloway Health blog page I thought ‘hmmm – I’m not a clinician, what could I possibly write that would be of interest.  Let’s give it a go!          

           

My name is Samantha Johnston and I am the lead for the Patient Advice and Support Service (PASS) which is a project delivered by Dumfries & Galloway Citizens Advice Service.  I also maintain and promote D&G CAS through the use of social media.  You can find D&G CAS at www.dagcas.org where you will find a range of useful information on our projects as well as updates on the forthcoming welfare reform changes. Or you can visit our twitter account @DAGCAS

As patient adviser, I have been listening to the patient experience in Dumfries & Galloway since the launch of the Independent Advice and Support Service set up in 2007 which was later rebranded to PASS in 2012 with the Patient Rights (Scotland) Act coming into force.  The introduction of the Charter of Patient Rights & Responsibilities also summarises the rights & responsibilities expected for all NHS users in Scotland.  Focussing on communication & participation: What does that mean for patients?  For me it means an increase in communication, more information about my health so that I can participate in any decisions made about my health.  You can take a look at the charter for yourself by clicking on the icon here –

                                                           

Social Media in Healthcare – There are many forms of social media in which technology allows users to easily create and share content including text, images and videos.  As an active social media user since 2007 I have tried a few but my personal choice is Twitter. Why?  Because it’s quick, easy to use and keeps me up-to date with what’s going on in other health board areas as well as updates from organisations such as Patient Advice, Patient Opinion, NHS Education for Scotland and Health Improvement Scotland.  You will find all of these on twitter via @PatientAdvice @PatientOpinion @NHS_Education @online_his.   

What started out as a bit of fun for me quickly became a place of knowledge and learning which enabled me to engage with like-minded individuals who have a keen interest in the patient experience and health improvement; I have also established some very useful contacts that I can signpost patients to should the need arise.

In my first year of tweeting I had witnessed a number of health boards taking to twitter to communicate and engage with their communities and as my excitement grew, it was becoming apparent that Dumfries & Galloway was lagging behind. 

Not good! I had mentioned this to NHS staff, tried to establish who dealt with communications but was unsuccessful.  Aaargh, frustration ensued.  Eventually however NHS Dumfries & Galloway established a twitter account (hurrah) @DGNHS and it is very good but was it enough?  No was my answer, putting people at the heart of the NHS which respects individual need must be coordinated in a way that provides choice to the patient and although their twitter account is informative, they were not really engaging in the way that I felt they could be.

Break through and my excitement grows again.  I was invited to attend an enhanced patient experience event at NHS Dumfries & Galloway education centre and with that I came across Dr Ken Donaldson – finally I had found someone who was keen on the use of social media in healthcare within Dumfries & Galloway.  It was an excellent day with various front-line staff (including the medical director & CEO) engaging in the patient experience.  I had left the event feeling invigorated in the fact that Ken was making an impact by using social media to communicate with his audience on the patient experience. Further developments meant the launch of the DGhealth blog and I am encouraged to see that it is going from strength to strength.  Big thanks and well done to Ken for being brave and taking a leap of faith by bringing Dumfries & Galloway NHS into the realms of social media.

                                                           

Whether you have not yet begun or you are already actively engaging, social media is here to stay and there are a number of relevant policy documents and drivers that make the patient experience an imperative. A useful place to start is the Scottish Government’s eHealth strategy 2011-17 which sets out a vision that affirms the view that information and communication technologies are as important to the improvements in quality as are the ambitions set out in The HealthCare Quality Strategy for NHS Scotland. 

Of course there are barriers to using social media in healthcare including patient confidentiality, patient/physician boundary issues and professional liability. These barriers however can be overcome if used in the correct way. The question should not be “Do we use social media?” The question should be, “How well can we use social media?” What are our aims? What is the message we want to get across and who will be our audience?

Access to on-line information has created an opportunity for non-clinicians and patients to take a more active role in healthcare.   To actively support and enable quality improvements in healthcare across Scotland, the NHS must work with the people who use services to make these services better.  

Samantha Johnston

Patient Adviser

Patient Advice & Support Service

Next Weeks blog will be by Dr Jean Robson, GP and Director of Medical Education NHS Dumfries and Galloway

Be kinder than necessary by @kendonaldson

“Be kinder than necessary, for everyone you meet is fighting some kind of battle”
                                                                                                            T.H. Watson

Not long after joining the renal team in Dumfries and Galloway I met Audrey, a peritoneal dialysis patient in Stranraer. She was quite a character, “larger than life”, and whenever she came to clinic she brought her Husband, Paul. They were inseparable, soul mates, and made most decisions together.

 
Sadly, a few years ago, Audrey’s health declined and despite all our efforts it became clear she was approaching the end of her life. The conversations we had around stopping dialysis were difficult but more so for Paul who couldn’t bear to let her go. As is often the case Audrey had come to terms with things some months before and was clear about her decision to stop dialysis.

 
She was transferred from Dumfries to Stranraer where she passed away peacefully two weeks later. I heard the news on a Monday morning and was saddened at her passing but glad that it had been peaceful. She was 51.

 
The next day I was doing my ward round when I did a double take. Paul was sitting in a four bedded bay looking a little lost. I approached him and asked why he was here. It transpired that he had had a small heart attack three days before Audrey died. The team in Stranraer had kept him there until she passed away but then, on that day, he had been transferred for Cardiology review. He was now sitting in a bed that was directly opposite the room his wife had occupied just a few weeks before.

 
This man was in torment. He said to me “Ken, I’ve been told I need an angiogram. I just need to get it over and done with. I need to sort out Audrey’s funeral and a number of things.”

 
I approached the team looking after him. He had been seen by two junior doctors. I asked what the plan was and told that he would have a treadmill test and echocardiogram and then see the Consultant on Thursdays round. I asked if they were aware of his current circumstances and was astonished to find that they were not aware that his wife had died the day before. There had been no mention at the morning huddle and the consultation had left no opening for Paul to bring this up.

 
In the end I spoke to the Cardiology Consultant and he had an angiogram the next day and got home. Paul was able to arrange the funeral, organise the family and say goodbye to his wife.

 
So why am I telling this story? It’s not to offer any criticism of the teams involved but to raise the concept of empathy. When times are tough and we are all busy it’s often the first thing to go. Not because we can’t empathise but because we are so busy we never get the chance to ask simple questions like “What matters to you?”

 
The Francis Report into the failings at Mid-Staffordshire is a lengthy tome with several hundred recommendations but it has been said that, at its heart, there was a failure of empathy.

 
I recently saw a short video on you tube that was made by the Cleveland Clinic in America that highlights this subject beautifully. It’s just over 4 minutes and you can watch it here. I am aware it is a little ‘American’ but I firmly believe anybody working in healthcare today should be able to identify with the message.

 
On September 6th we shall be running our second Enhanced Patient Experience event. Throughout the day we will discuss patient stories like the one above, exploring values and asking ourselves what we need to do to enhance the patient experience. The pilot in November last year worked well and I would encourage you to consider coming along to the second outing. For more information about how the day runs you can click here to see a poster with a little more detail. If you are interested then please discuss with your line manager about putting a team together, the more ‘multi-disciplinary’ the better. You can also discuss with Peter Bryden, Risk, Feedback and Improvement Facilitator Tel: 01387 241739 (ext 33739)

 
Let’s try and take some steps in our patients’ shoes, see life from their side, ask the question “What matters to you?” After all this is not a new concept…

“It is more important to know what sort of person has a disease than to know what sort of disease a person has.”
                                                                                                                            Hippocrates

 

(The names of the patients have been changed)

Ken Donaldson is a Consultant Physician at Dumfries and Galloway Royal Infirmary

Next weeks blog will be by Sam Johnston (@YeWeeStoater) from the Patients Support and Advice Service

Success is not the end by Susan Roberts

Success is not the end, failure is not fatal : It is the courage to continue that counts   (Churchill)

There is something stirring in the lower ground floor of DGRI. Over the last few weeks the hospital clinical pharmacy team have been busy polishing and admiring their award for Scottish hospital pharmacy team of the year.  We are equally proud of our senior pharmacy  technician, Melanie Bryan, who was  runner up as Employee of the year – leadership, against tough competition, at the Celebrating Excellence awards. The icing on the cake is our recently refurbished department which has improved work flow, the safety of our working environment and had a positive impact on morale.  I will share the highs and lows and why the shape of clinical pharmacy had to change. 

 As a keen, enthusiastic clinical pharmacist, tasked with setting up a clinical pharmacy service to the surgical unit, far too long ago in Stirling Royal Infirmary, I used to whizz round at least 4 wards daily checking every in-patient chart and reviewing patient’s medical notes. Even though this was a Monday – Friday service I was up to date with all medicine changes. Many patients stayed a week or longer. I had time to discuss medicines with the patients as well as providing advice to the clinical team. 

 I don’t need to explain that healthcare has changed since those golden days for clinical pharmacy. Like other services we needed to review ours to meet the needs of todays patients. We can’t see every patient every day, even Monday to Friday, due to shorter admissions and increased demand. How can we target our medicine expertise to the patient’s that need our in-put most and the activities that add greatest value?   We knew we had to work out how to do more with the same staff resource. Where to start?

With the help of Joan Pollard we set about process mapping. We suspected it was chaotic but once mapped we could see clear areas where our service was duplicated and confused particularly at admission.  We also identified, in our opinion, two points which provided the greatest patient value. The pharmacy contact with the patient on admission and discharge. We knew we had to focus on providing the best service we could at these points for as many patients as possible.

 We developed an admission process in medicine and surgery that utilised the skills of the team more efficiently.  The role of the pharmacy technician was extended to include checking patients own drugs, against medicines reconciliation sheets and in-patient charts.  To release this resource we had to disinvest in pharmacy technicians providing a kardex top-up service to the wards. This was not adding value and unless we could provide this service 24/7 to every patient, doing it once or twice a week was inefficient and could be argued was a risk. We agreed this plan with senior nursing staff.

 Targeting our clinical pharmacy service to those who needed it most was our next goal. As part of an MSc project, Lizzie Cook developed a triage service on admission. In the past pharmacists covering non admission units had to resort to identifying patients who needed to be seen by starting at one end of the ward and working their way round . The risk was that the patient who most needed your in-put was the last to be seen or worst still was not reviewed at all.  A very labour intensive process.

 Pharmacists in ward 7, whilst providing input to the clinical team, screen patients to identify any pharmaceutical issues, categorise the patient according to the required review frequency and communicate this to the pharmacy team.  Those at lowest risk are not seen until discharge. High risk medicines are added or the patients ability to handle medicines may alter during their stay and we still rely on referral by clinical teams to highlight patients who need seen more quickly than planned.  Electronic prescribing will help us identify these patients in the future.  The triaging system is allowing pharmacists to spend more time utilising their skills following up high risk patients, ensuring patients go home with the right medicines in close liaison  with the patient/carer and ensuring cost effective use of resource for individual patient’s as well as the organisation.

At the same time we have developed the discharge service.  From a baseline of 0, now 75 % of patient’s Monday to Friday have their discharge prescription reviewed at their bedside by a pharmacist (excluding paediatrics, obstetrics and palliative care). IT development of the Immediate Discharge Letter system which includes a colour coded progress tracking system allows better management of workload. These changes have reduced our discharge prescription turnover within pharmacy from an average of 4 hours to 54 minutes.

 Failure is not fatal (usually)

Although it sometimes feels like it. What went wrong?

There were days or sometimes weeks when it seemed like the easiest thing was to return to our old ways. It has been hard for staff to accept that we don’t aim to review every patient every day. It’s a struggle to maintain momentum.  There was a temptation to try and change too much too quickly, probably by me, which we had to curtail.

 There are no prizes for identifying our glaring error. We haven’t sought the views of patients or carers.

 It is the courage to continue that counts (As our rowing teams know only too well!)

 

So what next?  Our vision of a super slick service must take into account views of patients in conjunction with the pharmacists knowledge of a patient’s pharmaceutical need. As we continue to review the service and ask “What matters to you about your medicines?  We may be surprised by the answer. 

 We have an excellent team, we need to continue to optimise the use of our skills. We must consider ways of providing a service where all patients receive the same in-put regardless of admission time. Pharmacy assistants will play a greater role in medicines management and help to reduce waste. Supporting nursing staff to ensure medicines are in the right place at the right time.  Whilst pharmacists and technicians ensure it’s the right medicine. 

 So there is no rest for the pharmacy team, despite our success so far, and we wouldn’t want it any other way. 

Susan Roberts is a Clinical Pharmacist at Dumfries and Galloway Royal Infirmary

Next weeks blog will be by myself, Ken Donaldson, and will be entitled “Whose experience is it anyway?”