Getting to know you, getting to know all about you…by @rosgray

 How much time do you spend in work? We full timers spend about 225 of our 365 days a year at work, spending about 1687 hours (well those we’re paid for!) in the company of the people we work with and patients we care for – but how well do we know them?

When you consider that we probably spend more time with these people than we do with those we choose to spend our lives with, think again, how well do you know them, what’s important to them and what are their (and our) little idiosyncrasies that can make or break a relationship!

 

What’s that old saying? – you can choose your friends but you can’t choose your family? Well unless you’re the recruiting person and you’re starting to recruit a new team from scratch then co-workers fall in to the family category! As for patients and their families, then even more so, they are tied to us and we to them, for the duration of their healthcare experience, like it or not.

 

In my opinion, it is really hard to maintain good relationships unless you work at them (I include spouses and significant others in that!). Yet do we invest in this critical interpersonal activity? I suspect many of us don’t in our personal lives and perhaps even less in work.

That’s why I was so intrigued with something that emerged from the Scottish Borders as part of their work on the @EYCollaborative where we are working across multi agency partnerships to make Scotland the #bestplacetogrowup.

 

They appreciated that in order to work effectively across a multi-agency team they needed to get to know each other better, to understand the different professional backgrounds that were coming together to work on service improvements with and for the children and families in their care.

The Scottish Borders @BordersEYC has a rich history of song and they decided to form a choir to use the power of song to join them together as a community. We have followed their lead in the Scottish Government and used improvement methods to improve our performance with an aim to sing to our 800 person learning session at the end of October (#terrified).

The medium for getting together is academic – what I am suggesting here is that perhaps we need to do something out of the ordinary to connect or reconnect with the people we work with, to get to know them better in a different context that will then make it easier to understand any issues they or we may have in a work situation.

 Better understanding and closer relationships may lead to a better outcome – is my theory!

And what if it doesn’t? Then you’ve had a nicer time at work – win win!

 So how do we do that, and how do we learn from other ‘Great Organisations’ that do this well?

Our American colleagues would promote this as ‘Joy at work’ and there is a lot written on how to achieve this nirvana, such as that in Dennis W. Bakke’s book of the same name:

“Imagine a company where people love coming to work and are highly productive on a daily basis. Imagine a company whose top executives, in a quest to create the most “fun” workplace ever, obliterate labor-management divisions and push decision-making responsibility down to the plant floor. Could such a company compete in today’s bottom-line corporate world? Could it even turn a profit?”

 

Now I am not suggesting that the NHS and other public sector agencies across the country are quite ready for this level of intervention, but I think there are things we could do.

Let’s start with a simple intervention described by a physician/patient @GrangerKate who as a patient became very aware that people often came along and didn’t introduce themselves. How hard can that be? And if we do, how do we do it?  “Hello I am Professor Dame Rosamund Gray and you are honoured that I have spared the time to talk to you today” – joking (and aspirational – the Professor Dame bit that is not the totally up myself bit!) but I’m sure you can relate to the sentiment. We’re all busy, busy but taking the time to better connect with colleagues, patients and families in this way can reap great rewards.

 

 If you were to take the mood temperature in your work place right now what would it feel like?

Many authors (such as Jo Manion here) note that a ‘positive mood has been directly linked to a range of different performance-related behaviours, including greater helping behaviour, enhanced creativity, integrative thinking, inductive reasoning, more efficient decision making, greater cooperation, and the use of more successful negotiation strategies’.

So is this something to test and celebrate – or improve – in your area? If you were to do one thing, what would it be?

Remember how much time you spend in that work place – make it the #bestplacetowork and people will flock to be there with you!

Ros Gray works for the Scottish Government and leads the Early Years Collaborative (@EYCollaborative) which aims to improve the lives of all children, aged 0-5, in Scotland.

 

 

Clinical Care and the Financial Challenge – How do we Respond? by Mike Pratt

When I was at school I was uncertain of what I wanted to study at university.  Two front runners were Accountancy and Pharmacy.

Obviously I chose Pharmacy, and I have been very pleased with that choice.  This profession has given me opportunity to carry out work that has greatly satisfied me and hopefully has provided some benefit to many patients and I have tried to help other members of staff along the way.

 

However the job is changing and I did reflect to someone recently that I am beginning to feel as much like an Accountant as I do a Pharmacist. 

 

This of course is partly because the NHS, and the country, is in financially difficult times.  We also have an aging population which brings with it increased health challenges.  But it is also because we have seen some very major advances in medicines, some of which come with a huge price tag.  In particular the introduction of highly effective biologic preparations, with very specific and targeted drug action.  This is the result of some very sophisticated science, of which I am struggling to maintain my understanding.  Indeed when I read of a future where big pharmaceutical companies are involved in licensing stem cell products to treat a range of conditions including cancers, cardiovascular diseases, CNS disorders and diabetes, I start to feel well out of my depth.  And I dare not even consider the cost of these treatments. 

Couple this with emerging work in the area of genomics and stratified medicines where vast amounts of clinical, lifestyle, environmental, genomic and biological data is collected for a patient, allowing us to move to individually tailored treatment and therapeutic strategies.  We move away from standardised medication dosing towards made-to-measure medicines.  It is believed this approach will improve the lives of millions, of chronic disease patients.  If you are struggling to understand any of this, don’t worry my brain is starting to melt at the thought of it!  But again it will not be cheap!

 

The new biologic medicines we currently have, have revolutionised care.  In ophthalmology we can now stop some patients going blind with a regular injection, in rheumatology we have greatly improved the lives of arthritis patients, we have reduced the number of relapses multiple sclerosis patients experience and significantly reduced their rate of deterioration and we have improved the survival rates in a range of cancers to name but a few of the care benefits.  But whilst as a healthcare provider we rightly celebrate these successes, the down side is they come at a huge cost at a time we have little money.  This Board I have to say, has done extremely well to find funding for these medicines. This should be recognised and applauded.  But if we have a financial challenge now, then a glance to the future is clinically exciting but financially frightening!

 

So how do we deal with a future that comes with seemingly endless opportunities to bring clinical benefit and yet no significant increase in the resource we have to deliver this?

 To a large extent my answer is  – I don’t know!  But I do know we can’t expect our Finance colleagues to continually bail us out.  We are all in this together.

 There are some common sense steps we can take to increase the effective resource we have.  Simple steps that we are doing, but must continue to do with increased vigour:

 Reduce waste at all points of the health system. 

 There is not much waste nowadays I hear you say.  Well research carried out by the University of York indicates around 10% of medicines prescribed are wasted.  For us that means that with a budget of around £40m, perhaps as much as £4m is wasted.  So there is work to do.

 I also need to highlight that if there is 10% waste in a reasonably controlled process such as prescribing, what waste is there elsewhere? 

 Whatever you use, use it properly

 Research has shown that around 10-20% of hospital admissions are associated with medication related incidents.  By developing models of working across the whole care team including the patient we can improve on this greatly. 

Use the most cost effective products

In prescribing we have made many great improvements in this area, with a high level of adherence to prescribing policies.  We could however still improve, we need to challenge each other on this.  We also need to look at all areas of healthcare and feel free to challenge each other.

All these above are very important and will help us to sustain our position for a little while.  But the scale of the challenges we face in the future will not be dealt with by good housekeeping.  We need to consider some more fundamental changes.  This we cannot do alone.  There are 2 other issues I think we need to deal with as a priority.

 Understand and Work with Our Population

We need to work with our patients and with our population to determine what they want and need.  It might be surprising!

 

Research carried out by respected organisations, such as the Health Foundation and the Picker Institute has shown that the patient and the population can take a very mature and sensible view about healthcare priorities.  Indeed it has been demonstrated that affordability is a factor that citizens recognise as being important, as long as they can also have an opportunity to influence decision making.

 

Research by the Centre for Health Economics & Medicines Evaluation in Bangor also showed that the public had some very clear views on priorities and for example were not prepared to pay more for medicines that prolonged end of life, treated children, rare conditions or disadvantaged populations.

 

Whilst this is very interesting, all it says to me is that we need to understand our population.  We need to ensure that when the real difficult times come, we are all working together with a clear agenda.

Finally we must:

Change the way we do things

One of the great things about NHS Dumfries & Galloway is that it is full of good people, who are great to work with and are reasonable.  We make reasonable decisions.  However I am reminded of a quote by George Bernard Shaw:

The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man.

 

As we approach truly difficult times perhaps we need to encourage the unreasonable man (or woman).  We cannot keep on doing what we are doing and expect a different outcome.  We need radical change, and we need to do this in partnership with our population.  So come on stop being so reasonable!!  Lets challenge ourselves to deliver things in a different way to allow us to benefit from an exciting future.

Mike Pratt is Chief Pharmacist at NHS Dumfries and Galloway

Those were the days… by @ElaineRoss1985

Aah yes, when nurses were mainly female, a male nurse was a novelty, we wore white dresses, American tan tights and hats that lived in our lockers on top of our lace up shoes. Hats which we only replaced following head butting a pillow whilst performing Australian lift!

Doctors were God and not to be challenged, the only walk round  we did was when the Director of Nursing popped up and asked you to take her round the patients questioning you on each one and very occasionally we were visited by minor royalty. 

Discharge planning was undertaken in the bathroom and we rolled ‘pinnies’ or did the flowers during visiting time. The green water was carefully poured down the sink in the patients’ bathroom where we encouraged them to wash themselves. Then we were surprised when they got Pseudomonas wound infections! C.difficle was unknown to us but we knew that our post op patients had diarrhoea and it had a farmyard smell. MRSA was something you got in city hospitals and if transferred from one you spent days in a side room until we knew you were “safe”. Our first infection control nurse was funded due to nationwide concern over HIV (remember those tombstone adverts everywhere?) yet HAIs kill more patients than HIV.

We were kind, compassionate and largely clueless about evidence based practice. Doctors and nurses were never questioned by patients because we knew best. I splinted and bandaged all cannula and I made countless Kaolin poultices and placed them on inflamed sites (I loved that smell). Oh yes and there were always lots of nurses and time to spend with the patients… Or was there?

So as young staff nurse at the dawn of the 90’s I was sent to take charge of a surgical ward. I was the only trained member of staff and was supported by 2 students and with another trained member coming on at 3pm. A student came running for me. A man in his late 60’s had recently had a hernia repair and now he was holding his open abdomen and the bed was covered in pink pus. A surgeon was called and examined him without gloves or hand hygiene. ‘This is already infected’. He removed a gangrenous testicle in the room. I was horrified. I stood with my arms across the door and insisted he wait until I had a sterile pack brought from theatre. Whilst this was happening I spent time trying to source a pressure relieving mattress as this chap was clearly now at high risk of developing a pressure sore and I needed to move him from the carnage that was his bed.

That man died, not of the hernia though I believe that was an entirely preventable infection, but from an infected pressure sore. He came in for a routine operation and died before his time. We had no targets and little inspection so this catastrophic event went unnoticed.That experience kindled an interest in pressure and wound care that led me to the role I have now.

These days we do have targets and inspections and I believe they have brought improvement. We count everything, we can have data overload at times but in the past we didn’t know, issues were invisible to us rising to epidemic proportions before they were addressed. Just look where we were with C.difficle a few years ago.

Now if I say we are going to miss a target or we are at risk of failing an inspection there is support and resource there that was not available to me before. But it is not simply about meeting the targets and not looking bad in the press. They have focused our attention on things that matter and that means on our patients and those who care for them.

We state as an infection control team that our vision is that no person will be harmed by a preventable infection. Despite, this we estimate in the past year around one third of all Staphylococcus Aureus Bacteraemia in NHS D&G may have been preventable. That’s amounts to 13 people and has an estimated cost of £26,000. In addition, national data indicates that in these people Staphylococcus Aureus Bacteraemia amounts to a 1 in 3 chance of dying as a result.

So next time we are checking cannula use please understand it’s not about targets it’s about people who we want to see leave hospital in a better state than when they came in and certainly not harmed by our care. 

As for those Doctors and nurses that know everything, well let’s share that with our patients and encourage them to ask. Do I need this cannula? Have you washed your hands?  Don’t take offence; take it as a compliment because you have the answers.

 

 

 

 

 

Elaine Ross is the Infection Control Manager at NHSDumfries and Galloway. Next weeks blog will be by Mr Mike Pratt Chief Pharmacist for NHS D&G.

 

Ethos by Laura Jones

It is heartening to see how much development and reflection is happening in the central area of patient care in NHS D&G. Dr Donaldson and others are to be congratulated for bringing this area to where it belongs- at the core of what we do in our daily work.

The key word seems to be consideration, taking time to really see the patient as a person and acting on what we see. It seems to mean being person- centered before process or pathology.

Would it be feasible to extend this open mindedness laterally also?

We all work in teams in the Health Service. The NHS is the largest employer in Europe…that’s an ‘awfy lot of people’. How well do we relate to those other people who are our co-workers in this amazing endeavour that is the NHS? Could I suggest that the best measure of this is not based on a computer checklist but inside ourselves…how do we feel?

As a GP I regularly communicate by telephone with DGRI and many others in allied fields. I worked in Outpatients for a time also giving immediate contact with any of the hundreds of people working in the Hospital on a given day. More recently I have been employed as a GP locum across the region. At the risk of crudeness I can (like all of us) sense the ethos of a workplace in my gut.

Is it warm and helpful or off -putting and officious?

It is in the tone of voice before a phrase is uttered.

It is in the body language- a smile that says “I have time for you’ / ‘I see you as another person trying to do what is best for your patient- not a problem’.

It is also there in how the staff in a location interact with each other. Is it respectful and supportive or brusque and dismissive?

Across NHS D&G a huge deal of the former and much less of the latter happens. It is there from the telephonists in DGRI through medical secretaries, laboratory staff , Nurses and Health Care Assistants and so many others. In Primary Care it is in medical receptionists with their understanding of elderly patients on the phone or at a desk, the welcome of Practice Nurses and the commitment of GPs. Paramedical teams like Physiotherapy or Podiatry go the extra distance that makes all the difference.

(The picture above is of the Welcome Desk ladies at DGRI. A member of the public recently posted a lovely comment on Patient Opinion about them which can be read here)

Each small effort contributes to the building of ethos. It needs to be valued for the vital component it is. Can we learn to say thanks more often- especially those in positions of power and management? Just a moment to say ‘I appreciate your help’ or say in an e mail – ‘you are doing a good job there’ creates positive waves that flow far beyond that simple contact.

For a brief time I had the pleasure of working with medical students and junior doctors in DGRI reflecting on their experience of the hospital…not the hospital as building but the hospital as people.

I was blown away by their positive feedback. Everyone commented on how welcome they felt, how supportive everyone was and how much better an experience they had as a result. Sadly, they had felt this had not been the case in big teaching hospitals in the cities.

So we have a good ethos in D&G – but it needs to be treasured and nurtured. If we value and respect each other then doing the same for patients and their families follows naturally.

It is something that needs to be nurtured and valued and can be lost when not prioritised.

The consequence of losing sight of the value of the individual has been brought home to me as I am currently working 12,000 miles away in New Zealand. Christchurch Hospital has a huge core of Uk doctors working at all levels. It appreciates its doctors from the UK who are well trained, speak excellent English and fit into the Kiwi way of life like a hand in a glove.

On first questioning they usually say they are here for the adventure. Question a little deeper and there are other drivers that have brought them here.

These invariably include words like valued, respected and not feeling that happened in Britain. It goes along the lines of  ‘working my socks off to get into medical school, continuing to work hard and knowing that would continue in my hospital jobs but there would be the pay back of doing a good job. Instead I worked shifts that left me unable to get settled in the same ward or the same team.Seniors got frustrated and so did I. Then I wanted to progress and hit up against MTAS*. I felt like a widget made in the factory of medical school who was just to be parcelled up and sent anywhere.I had little say and there was nobody to listen- just a computer.

So I came out here and I feel like a person who is respected for my skills and potential.’

This story of expensively educated young British doctors is repeated across New Zealand and Australia.

Some will return home- where they are badly needed. More will not and we have lost a valuable asset. The root of that loss is not valuing what we have and allowing an industrial process be applied to people.

There are people in D&G in senior management and consultant level who can influence what is happening with the training of our young doctors at national level. They need to use that influence and force the decision makers to listen.

Most of us do not have that influence. However, in continuing to make D&G a good place for all of us to work we may entice back some of our former medical students and junior doctors. That can only benefit us all who work for NHS D&G and the community we serve.

*MTAS – Medical Training Application Service -the UK wide computerised system which allocates all medical training posts.

Dr Laura Jones is a GP who works between Dumfries and Galloway and New Zealand, from where she follows our blog.