In the last month I have experienced the NHS as a parent, as an improvement advisor and as the programme lead for the Person Centred Health and Care Collaborative. This has taken me from disappointment with the system to great hope for the future.
My youngest son is a typical 6 year old and likes trees, with the usual hazard of falling out of them leading to a fractured forearm. This happened at around 6.30pm on a Monday night about a hour after his tea, which will become relevant later in this story. We went straight to nearest minor injuries unit where he was treated quickly as it was quiet and the staff were great with him. He had been given pain relief and had a temporary plaster in place and was no longer ashen grey. This is where things started to go wrong with a telephone consultation at about 7.45pm with the orthopaedic registrar at the nearest larger hospital. He viewed the digital x-ray and advised that we come to the fracture clinic that evening to have the fracture set properly. The minor injuries unit staff were surprised as it was usual to go home and go to the clinic in the morning but we were assured that if we got there before the clinic shut at 9.00pm we would be OK, so off we dashed.
We arrived at the fracture clinic at about 8.20pm to be told rather abruptly that the clinic does not accept referrals after 8.00pm and we would have to go to accident and emergency. So the long wait started with the triage nurse frustratedly commenting that the fracture clinic staff had no patients but they had fifty-eight! We waited until about 11.20pm for a doctor to see my son and do another telephone consultation with an orthopaedic registrar who decided he would be treated in the morning. He was then admitted at about 12.30am even though I questioned the need for this and was told they wanted to keep an eye on him. Fortunately my wife was able to stay on the ward on a z-bed and eventually he was taken to theatre at around 12.00pm on Tuesday and then finally able to drink and eat something at around 2.30pm. This last point is where the experience was poor for my son as he had not had anything to eat or drink since 5.30pm the previous day, 21 hours ago. This was all due to the presumption that he might have a general anaesthetic whilst waiting in A and E and then by the time the decision to defer treatment had been made the pre-surgery protocol kicked in with fasting from midnight the day before surgery.
Apart from the abrupt manner of the fracture clinic staff all the other staff were great with my son. However, the system failed in several ways leading to a poor experience, an unnecessary admission and an extra person waiting in A and E putting pressure an already busy system.
At several steps we could have been involved in the decision making and given choices. At the fracture clinic we could have been told honestly that you can wait at A and E but it will be a long wait and he may not get treated tonight or he can go home have something to eat and drink and return in the morning. We could also have been offered the option to be admitted or return home with a checklist of things to keep an eye on, which as concerned parents we would have done.
It was the system that caused care to be less than person centred even though each member of staff was doing the right thing from their perspective and in a pleasant and caring way. The challenge is to think differently and involve people in both the delivery of care and identifying ways we can improve it.
This is what I saw as an improvement advisor on a visit to Dumfries Royal Infirmary where I saw the work ward 12 have started with a staff ‘huddle’ everyday for 10 minutes to reflect on the day and discuss what has worked well and what could be improved.
This picture shows how they are using systematic approach to measure if they are achieving their aim by marking if the huddle happened for each day during the month on an adapted ‘safety cross’. It also shows boxes used to collect notes identifying things that are going well and things that could be improved to aid their reflection and also prioritise what ideas they will test to improve care for the people on their ward. They are also about to test a method for regularly asking people on the ward ‘what matters to them’. This ‘system’ approach helps to make it easy for staff, people receiving care and those closest to them to share concerns, make suggestions for improvement and work in partnership.
Many places where care is provided could use improvement methods like ward 12 to develop a reliable system to support person-centred care and make doing the right thing easier. Sharing these great ideas and ways of working was the main purpose of learning session 4 of the Person-Centred Health and Care Collaborative. Healthcare Improvement Scotland hosted the event with over 500 people attending over 2 days at the SECC in Glasgow to share their experiences and learn from each other. It filled me with great hope as I heard many people talk of the new ideas they were going to take back to where they work and test with their staff and the people who use their services.
The enthusiasm is reflected in this photo of the commitment of a thousand hands with 500 delegates making an action based pledge for each hand and sharing at the event. With this commitment we can transform health and care so that we always see the person rather than the patient and make progress towards a more person-centred health and care system. Hopefully this will lead to fewer experiences like my sons in the future.
Gareth Adkins is Implementation and Improvement Team Lead at Healthcare Improvement Scotland