What are you doing? by Ross Warwick

Ross 1If there was a camera trained on you right now like in Big Brother or The Truman Show, transmitting to televisions and tablets up and down the country, how would the audience see you behaving? Take a moment to notice what it is you’re doing. Are you sitting or standing? Are you mutli-tasking, trying to read this whilst having a conversation with a colleague? Are you tapping an NHS biro on the desk or drumming your fingers? These things that you are doing, whatever they may be, are behaviours.   

So if I was watching a monitor, observing that live broadcast of you reading this blog, I might make informed assumptions about why you were acting as you are. I might guess that your decision to sit or stand is perhaps motivated by a need to be comfortable; multi-tasking might illustrate a wish to get as many things done as possible; and drumming your fingers and tapping your biro might be impatience that I have yet to get to the point (SPOILER: you may be expecting too much…).

It’s not just psychologists who make assumptions about the behaviours of others; everyone does it. To help us make our judgements it’s likely we would call upon other contextual information. This might include the things we already know about that person, our previous contact with them, things we know are going on in the environment around them, their personality and so on. Furthermore, the conclusions we reach are filtered through our own particular view of the world and our mood at the time.

Ross 2Behaviour can be a rich source of information. Analysing behaviour can be of significant clinical value because all behaviour happens for a reason. It serves a purpose. If a behaviour didn’t fulfil a particular need then you wouldn’t do it. If by pressing a certain button on a broken vending machine you got a free Mars Bar then you would repeat the behaviour again and again. Once the machine had been repaired your frantic button tapping would stop (although only after a few bonus taps for good measure, just to be sure).

Considering behaviour and the needs it may be fulfilling is one of the central tenets of therapeutic approaches such as Cognitive Behavioural Therapy (CBT) and Acceptance and Commitment Therapy (ACT). In this context we are interested in the things that people do that are detrimental to their long-term well-being. In mental health that might be a depressed young man who doesn’t contact his friends or an anxious lady who has stopped going out. In these two cases the behaviours of interest serve an important purpose: they protect against harm. The young man is protected from his belief that no one wants to spend time with him because he’s boring; the older lady is protected from anxiety about falling over and injuring herself. Their actions have a clear logic when the reasoning behind them is explored.

In physical health the behaviour of interest may not be related to a mental health problem. Consider a patient who is at ease with a diagnosis of kidney disease.   However, they have not taken on recommendations regarding dietary and fluid intake, putting them at risk. So the behaviour here could be characterised as a failure to follow advice that would improve their physical health. See also a patient with COPD who continues to smoke; someone with Type I Diabetes who doesn’t monitor their bloods; the drinking habits of someone with liver disease.

It can be hard to comprehend such behaviours when the stakes are so high but there will be needs underlying them nevertheless. I would wager that most of us have tried to change our behaviour in order to improve our health and relapsed into old habits after a few weeks. I bet too that when quizzed there were a whole range of sound reasons why. Personally, I couldn’t find the time to keep running, plus my ankle was hurting. And it’s not safe to run in the dark round where I live. And the routes aren’t varied enough so it was boring. Look, just back off will you?!

In some cases the need to change is a priority for those involved in providing care, not the patient themselves. This might mean that our behaviour towards them will change as a result, driven by our own needs to make sure they keep well. If you were in such a situation and there was a camera trained on you, what might we see?

Attending the Emergency Department is a behaviour that fulfils an important need; to seek urgent medical attention. Patients who frequently attend also do so to fulfil a purpose but the reasons are sometimes complex and difficult to discern. I’m involved with a project in A&E designed to help understand why people frequently attend. This understanding leads to the development of management plans that colleagues can use to ensure patients receive the treatment that they require. We use the formulation below to help:

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Figure 1. Formulation model (based on James et al, 2006)

So how are you behaving just now? If you were seated are you standing? If you were multi-tasking are you now just reading? If you were restlessly tapping are you now still and calm? If so I choose to interpret your behaviour as evidence that my blog has succeeded in engaging you. Please feel free to challenge my assumptions in the comment box below.

Dr Ross Warwick is a Clinical Psychologist and Neuropsychologist for the Physical Health and Psychology Service at NHS Dumfries & Galloway




Quality and the dreaded hospital appointment by Martin Keith

Martin K 1Along with hundreds of other people my wife had a new outpatients appointment in October. “Big deal” I hear you say “so did my husband” but unfortunately my wife has severe long-term health problems and for us this was a challenge we were not particularly looking forward to. As she is housebound, confined to an electric wheelchair, intolerant of any noise and unable to stand for more than 30 seconds even a simple appointment is an expedition of Herculean proportions.

However rather surprisingly and to our great pleasure the whole visit to DGRI was a fairly simple and stress free experience. I had arranged for a quiet room in the department for my wife to wait for her appointment and we asked the departments she was visiting if they could phone when they were ready so we didn’t have to wait around in noisy waiting rooms. All the staff we came into contact with were as helpful as they could be and did everything they could to make the experience as easy as possible for my wife. Although it may at times only have been little things or minor changes to normal practice they made my wife feel more comfortable so to her they mattered and were appreciated. I’ll put my hands up here and admit that the fact I work in DGRI helped as I had the knowledge of the building and the services my wife would need to access. However you do wonder how many other patients have a less than pleasant experience when visiting the hospital simply because people were unaware of their needs or the challenges they faced getting to hospital in the first place. So how do we measure the quality of the services we deliver to our patients?

At the end of 2004 the NHS Dumfries and Galloway decided in their wisdom that I was the ideal candidate to be sent on a 3 year BSC Adult Nursing secondment at what was then Bell College. At the time I was working in IT as an Information Officer producing exciting reports on bed occupancy, waiting times and other information requests.   So I headed off to college for 3 years of hard work, extensive study, long holidays and copious drinking and quickly realised that for much of the last 5 years I had been producing work that whilst accurate was actually fairly one-dimensional in the great scheme of things (and fairly useless a lot of the time). Numbers matter but they don’t tell the full story; for example in my previous job I had been asked to provide information on a ward’s workload as the ward involved claimed their workload had massively increased. The data did not show a change in admissions, discharges and length of stay for patients in that ward over a 2 year period so on paper the workload had not increased. However due to a change in the patients admitted to the ward the amount of time required to deal with each patient had increased thereby increasing the workload considerably. I learnt how hard work a shift on this ward was as a student and since then have been very aware of the one dimensional nature of data and how it only tells part of the story.

Whilst I found nursing very stimulating and enjoyable in a challenging way a change in supplier of hospital soap led to my hands starting to bleed and crack hideously. For some reason there was a feeling that my ability to bleed spontaneously was not really necessary for a career in nursing, in fact it was positively discouraged and so this led to another change in career and I washed up in Cancer Services doing cancer audit work, ie back to the data I’d hoped I’d escaped 5 years earlier. It quickly came apparent I was back to where I started, “counting procedures” rather than the measuring the “quality of the procedure”. It was also clear that the clinical standards we were being measured against were “voluntary” so there was no sanction for not collecting the data and no requirement to publish it openly so patients and other health professionals could review it.   Then in 2012 everything changed with the introduction of the Quality Performance Indicator for Cancer.

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“Better Cancer Care, An Action Plan” published by the Scottish Government in 2008 detailed the new strategy for measuring cancer quality across all of Scotland’s Health Boards Specifically the government committed to the following

“By 2010, all of Scotland’s tumour-specific networks will take part in national audit that will enable an ongoing programme of improvements to clinical practice, based on national indicators which allow benchmarking against other countries’ approaches”

As is often the case it was actually 2012 by the time we started collecting data using the new national audit framework. The significant difference between the QPI’s and the old clinical standards is that the collection and publication of data is mandatory and all the data collected will be available on the internet for all to view. In addition they have been developed by clinical, managerial and support staff working on a daily basis with and supporting cancer patients to ensure they are relevant to the clinical teams delivering care. However it was noted at a high level that in many cases we were still collecting data to ensure protocols had been followed rather than looking at the individual. Therefore the “Cancer Patient Experience Quality Performance Indicators” were born (to download any of the cancer QPI’s please click here)

Initially 3 Patient Experience QPI’s have been developed each dealing with a different area of the patient journey

QPI 1 Communication – Patients should experience excellent communication from healthcare professionals throughout their cancer care.

QPI 2 Information Provision – Patients should experience excellent information provision from healthcare professionals throughout their cancer care.

QPI 3 Shared Decision Making – Patients are empowered by healthcare professionals to share decisions about their care and treatment

Ok it won’t change the world but at least now the patient is at the centre of our audit work and we will have to ask them what they think of our service and we will have to share the results, warts and all, with all who want them. We are also still collecting an awful lot of data on procedures to ensure that clinically our patients receive the correct diagnostic tests and the appropriate treatments. So going forward in cancer we will be looking at the “whole picture” rather than just the medical side of the patient’s journey which will hopefully lead to improvements in the whole patient experience.

So for those who have managed to stay awake till this point we are back to where we started, how exactly do we measure the quality of a hospital appointment? I hope that the work that has been accomplished in cancer will eventually feed into other services with the same proviso that data collection and open reporting are mandatory. I also hope it actually makes a difference in the long term and we do see actual improvements in patient care and this does not just become a “tick-box” exercise. Whilst gathering data on the patient experience is very time consuming and surprisingly challenging it matters. Everyone reading this will at some point, either personally or through family members and friends, be affected by cancer. By concentrating on the individual and the quality of care they receive it is hoped that the QPI programme will mean that everyone will get not only the highest standards of medical care but also feel a welcome participant throughout their illness rather than a number.  

 Martin Keith is a Cancer Improvement Officer at NHS Dumfries and galloway







“Public Service –What’s that all about” by @Mac_imar


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We have seen from recent blogs that we celebrate 66 years of the NHS (Happy Birthday NHS !!!!! by @shazmcgarva & @Emmcg2, 04 July 2014) and that it is a treasure we hold dear as can be seen from the high profile it received during the referendum and the current focus as we lead up to a general election.

What was the original idea behind the NHS and the creation of the welfare state and what is the notion of public service and what, or perhaps who are we here for?

When William Beveridge in 1942 produced the blueprint for the welfare state he had” five giants” that needed to be eradicated, these were ignorance, squalor, want, disease and idleness. This blueprint ultimately led to the creation of the welfare state and the National Health Service that was founded by Aneurin Bevan in 1948.

In tackling these the welfare state grew into something he didn’t predict, an over professionalization of services that relied on high tech equipment, professional knowledge and sophisticated processes, which ultimately created dependence and lack of resilience within the communities it served.

This I think reflected some of the pejorative language we use, terms like our patients, my patients framed a “we know best” approach, but we now see the development of a more personalised approach which identifies personal responsibility and some degree of accountability to be involved in our own healthcare and become partners in collaboration rather than passive participants

A more facilitative partnership approach to delivering health care commonly described as Co-production drives a process to involve people in this sharing and supports the development of community resilience i.e. people helping themselves. This starts to shape our role into “helping people decide not telling people what to do” and was eloquently described by Shaun Maher in his blog titled “Keeping the lights on” (@Shaun4Maher, 22 August 2014) by the difference between asking “What matters to you?” not “What is the matter with you?” This approach is also well established within the Health Improvement work taking place in D + G and by Elaine Lamont blog “Services…but not as we know them” 26 September 2014.

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So how do we know if we are managing to do this effectively and provide high quality health and social care to those whom we serve?

Most commonly in the NHS and Social care a lot of what we do is driven by the need to meet various targets and attain levels of quality by implementing a variety of improvement programmes

Measuring what we do and telling our story of how well we are doing sometimes doesn’t match up, how often you have heard people say “that score or report doesn’t reflect accurately what we do”

It can be easy to become demotivated, frustrated and feel that what you do doesn’t have a positive effect and that you are drowned in form filling, report writing and action planning. A recent (2010) study called “the Bermuda triangle” found that in one hospital there were 515 projects all linked to improvement work, another hospital started a balanced scorecard approach with 4 strategic categories that then developed into 252 performance measures

This created increased workload and meetings which focused people’s attention on compiling reports and action plans to improve results rather than focus on the work that was being done on what you might call the front line

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So peoples behaviours and energies have been shaped by the tools which we have created, or as Marshall McLuhan stated “We become what we behold. We shape our tools, and thereafter our tools shape us.”

Euan 7Has the NHS moved away from its roots and purpose, have we lost something of what we had in our communities that supported and looked after people and helped them to be resilient, to ask questions, to seek solutions to be all they could be.

What are we trying to create with ideas of personalisation, co-production and collaboration and does this truly present us with a new model for a way forward in the NHS given the huge challenges we face, how can we engage the public in a debate about making the NHS better, harnessing the people’s ability to be part of the solution.

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One example of this collaborative approach came following the announcement in June 2014 by the Cabinet Secretary for Health and Wellbeing, Alex Neil MSP, that: “… we must do more to listen to, and promote, the voices of those we care for. We need the voices of our patients, those receiving care and their families, to be heard in a much clearer and stronger way” the Scottish Health Council working in partnership with Scottish Government officials, COSLA officials, and members of the Alliance, have been doing work on the ‘Stronger Voice’. Locally the Scottish Health Council has responded to this by setting up a “people’s database” , a list of people who are willing to be part of public involvement and in a way suited to them eg. Email, focus group, online survey.

(Contact: dumfries.galloway@scottishhealthcouncil.org to get involved!)

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So clearly most would agree that working in the NHS is at times stressful, chaotic, and a complex arena, with no easy answers, we might wonder if we are making a difference, we might think of the old days when things were better or have our own ideas of what needs to be fixed. Sometimes these things may appear outwith our direct control or even our ability to influence, but sometimes just sometimes there may be times when are able to exert control and influence for change.

Euan 9.2A colleague I worked with some time ago would always say “don’t give me problems give me solutions” and one way of looking at solutions has been a key feature of a therapeutic approach called “solution focused therapy”



Euan 9.3The Solution-Focused model emerged from the therapeutic arena of Family Therapy in the 1980s. Since then, its psychological principles have been applied to a wide range of fields, from mental health to organisational change. The model reflects the values of co-production as it affirms collaborative, personalised, strengths–based values and a clear focus on sustainable outcomes.

The aim of a Solution-Focused approach is to help individuals, teams and organisations develop constructive, customised solutions. It is therefore solution-focused rather than problem-focused. So the term indicates where we look: forwards, towards solutions, rather than backwards, by studying problems.

The approach commonly begins with the miracle question:

So my thought for you is this:

In amongst all the things we have to do, the daily grind of serving and caring when things can sometimes be a bit of a bother, the things that irk, whatever it is that bothers you about working in the NHS here’s a miracle question for you

Suppose….You finish your day, go home, go to bed and eventually you fall asleep

….And while you are asleep a miracle happens

….And this problem has vanished or things are how you want them to be

…..But, you’ve been asleep so you don’t know the miracle has happened. As you

wake up – in the middle of the miracle – what’s the first sign you notice that tells you

things are now as you would like them to be?

What do others notice that is different?

What are you doing?

What are others doing?

What else is happening?

How are people responding?

What is the positive impact of this for you and other people involved?

What else do you notice?

Who else notices what is happening?

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Feel free to share this with colleagues and allow yourself the opportunity to begin looking forward and not backwards

Euan McLeod is the Senior Project Officer for the National Bed Planning Toolkit

Reach your full potential – Dyslexia, my journey by Emma Groves

The message to “Reach your full potential” is very powerful for anyone with Dyslexia. What this message conveys is that with the right tools and the right help anyone with Dyslexia can excel. This message was highlighted through UK Dyslexia Awareness Week, 3rd to 9th November 2014. 

It is recognised that 10% of the UK population have Dyslexia and therefore there are potentially 450 people employed by NHS Dumfries & Galloway who have Dyslexia. There are many famous people with Dyslexia who have reached the top (their full potential) in their profession or sport e.g. Richard Branson, Steve Redgrave and Jackie Stewart.

Emma 1Dyslexia? What does it mean? Does it mean we get the B’s and D’s round the wrong way? If only that was all that we had to cope with and that was all that Dyslexia entailed.

Instead we can have confusion between left and right, organisational issues, timekeeping problems and difficulty remembering things just done or things to be done. But being hurried, pressured or ridiculed only serves to make the Dyslexia symptoms worse. People with Dyslexia need time to reason and understand a situation and do not benefit from Rote (learning from repetition) but have to Reason (seek to fully understand) each time they are faced with a situation.

People who suffer from Dyslexia have, as individuals, different strengths and weaknesses and are affected differently by their Dyslexia.

Most people, like me, find out later in life they have Dyslexia and miss the opportunity of their Dyslexia being addressed when still at school, university or college.

Emma 2I was diagnosed with Dyslexia at 34 and only then because of my attendance / involvement in a Learning Disabilities Course on behalf of the Day Surgery Unit. The Course content included references to difficulties with learning and I.Q and I recognised that I suffered from some of these symptoms. I then arranged an assessment with an Educational Psychologist for Dyslexia. When I discussed my symptoms I felt someone understood me and the difficulties in my life!

Emma 3The clues were there in my behaviours. I had always found it hard to keep up with the pace of life, while all around me my fellow pupils, peers and work colleagues appeared to find life’s challenges relatively easy to overcome. I tried very hard to cope because I like to do a good job but I was frustrated. Despite the personal improvements I sought to build on I would often have to start again at square one even for a situation I had successfully worked through previously.

My Dyslexia diagnosis has enabled me to piece together the jigsaw that is my life. I now understand why I had difficulties in certain areas of my schooling, life and job. I am working on ways to counter these difficulties, with help, understanding and tools for example glasses with green coloured lenses and varying the colours of paper and test I use. These are the things I need to enable me to “Reach my full potential”.

Emma 4My strength is that, as a Staff Nurse in the Day surgery Unit, I am recognised for my empathy with and good care of my patients, who often personally thank me for making their journey through the Day Surgery Unit as pleasant an experience as is possible in the circumstances. They also thank me for the high level of care I have given them.

However I do struggle to cope with the paperwork, time management and organising the team. These tasks are very demanding of me and I hope to improve on my performance in them by use of the tools and help that is now available to me and work with my colleagues to help them understand the effects of my dyslexia.

The possibility for everyone to “reach your full potential” is there because most people with Dyslexia have, on assessment of their intelligence, an above average IQ. Under the Equality Act there is a duty on the employer and employees to level the playing field by making the work environment Dyslexia friendly. This often leads to a better working environment for everyone involved.

I have driven the promotion of Dyslexia Awareness Week (3rd to 9th November) in NHS Dumfries & Galloway to help others to recognise Dyslexia in themselves or in their children and to make sure they know where to go for help and support if they or members of their family have Dyslexia.

Through Dyslexia Awareness Week I have met some inspiring people who wanted to share their Dyslexia journeys with me. I have also met people who have approached me because they have children or grandchildren with Dyslexia and were unsure of how to do their best for them.

It is my 36th birthday on Sunday, 9th November, what better present for me than the fact that I have spent Dyslexia Awareness Week promoting awareness and helping others with Dyslexia (or with Dyslexia in their families) through listening, understanding and directing them to where they can receive help and support. I hope this has made a difference to their lives and their achievements.

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Dyslexia Matters….

To the 1 in 10 people in the UK affected by Dyslexia.

Because with early intervention and the right support, people with Dyslexia can reach their full potential.

At School, at University and at Work, making the environment Dyslexia friendly can benefit ALL who are learning or working in that environment.

Emma Groves is a Staff Nurse in the Day Surgery Unit at Dumfries and Galloway Royal Infirmary