Just getting up and going to work by Phil Jones

My first memories of my younger brother Graham were bringing him and my mother home from the maternity clinic in August 1957. John Evans the Sunday school Superintendent and local shop owner, who had one of the few cars in the community, met us at the clinic and drove the two miles to our little cottage in Hawarden, Flintshire.
I was six years old and I carried Graham on my knee in a white shawl, I sort of looked after and looked out for him from then on as we were growing up.
Three brothers grew up together in a loving family home, we were an active, outdoor and sporting family and as I went on to play football in the local leagues Graham would come with me, that is until a new leisure centre was built down the road which included a full size ice rink, Graham suddenly disappeared into the world of ice hockey, training started at ten o’clock in the evening, and every evening, and he travelled all over the country, playing for the county and also achieving international call ups.
He left school to work in the nuclear industry, married, emigrated to Canada to work and play hockey and on returning to Wales a few years later had two children of his own.
Eventually Graham started to watch his son play football in the local leagues and his daughter compete in county and Welsh gymnastic events.
All was well until one day, at 40 years of age, running after a football that had gone out of play he stopped and thought to himself ‘ I don’t think I will ever run properly again’
After many tests and sleepless nights the symptoms, effects and consequences of multiple sclerosis were well known and much discussed in the Jones household.
Graham and his wife Barbara were soon to discover that Primary Progressive MS just gets worse and worse with no periods of remission. Barbara was soon to discover that becoming a carer was not a career or lifestyle choice, and it wasn’t much fun either.
One of their early decisions was to do every thing they could to give their young children as normal a life as possible and for Graham, who had a strong work ethic, this meant doing all the things that dads do including carrying on with his job, seventeen years later he is still doing it.
‘It’ being a job as a systems design engineer in a competitive market place. Graham had moved from a secure position in the nuclear industry to self employed status, firstly with Unilever research and then for the last 17 years in the petro chemical industry working for a company who are the world’s only manufacturer of lead additives for specialist fuels.

Nothing really remarkable so far? one of 100,000 sufferers of MS in the UK.
So its bed time Graham, you can’t stand, you can’t walk, you can’t take off your shoes, socks, and clothes. Well actually you can’t do pretty much anything at all.
So its Graham’s bed time Barbara, oh! in about 45 minutes so let’s get started right now, swing out the stair lift at the bottom of the stairs, move the cumbersome hoist out from the corner of the dining room, find the straps and body harness and using the hoist lift Graham from his chair and using all of your strength push the hoist with Graham into the hall and lower him onto the stair lift.
Power up the stair lift and off we go to the top floor, making sure you walk up first and are ready to manoeuver Graham onto the small wheelchair situated at the top and into the bedroom. Using the hoist in the bedroom, the one with the track in the ceiling, lift Graham from the chair and track the hoist into the bathroom. Undressed and bathroom stuff, that’s not as straightforward as it sounds, and then back into bedroom via the roof mounted hoist, carefully negotiating the contraption so that Graham is in bed, not just in bed but lying comfortably because he isn’t really able to move himself once lying down. ‘This isn’t what we planned our life out to be’ says Barbara. All the equipment around the house wasn’t how they wanted their home on the outskirts of Chester to look like either.
Before you know it, time to get up, same procedure in reverse, eventually Graham is downstairs eating the breakfast that Barbara prepared as well as the getting up, getting dressed and down the stairs stuff. Now he is sitting in his motorised wheelchair. Oh did I mention that he only has the use of one hand after slipping in work on washing liquid that had spilled out of a two-litre bottle that had been used to keep a bathroom door open. Health and safety at work, aye it’s got merit I suppose, especially if you use crutches to get around.
Until the accident at work Graham could just about get around using his crutches, but a broken shoulder and collar bone, followed by the insertion of a metal plate quite a long period of recovery and muscle wastage put paid to that.
At 0800, almost two hours after getting up, the doorbell rings and the driver of a converted taxi says ‘Hi Graham’ same routine five mornings a week and sometimes Saturday if there is an emergency call out from work. Graham drives his motorised chair out of the house, up the ramp and into the back of the taxi, a manoeuver that Lewis Hamilton would be proud of.
Off they go on the fifteen mile journey to the Merseyside chemical works, Oh lets not forget about Barbara, young wife and mother one day with her whole life ahead of her, the next and for the future, a carer. Barbara’s own day hasn’t started yet.
It’s Carers week in Dumfries and Galloway starting 8th June, might be worth calling in to get an insight, probably be quite surprised how good it would be for us to become a Carer Positive Employer.
Back to Graham, he is at the factory gate, reverses out of the taxi and down the steep ramp backwards, abseiling would hold no fears for him, no mean feat for anybody, and like the rest of the guys once in the plant he is just one of the boys, well not quite, he is the only senior systems engineer they have, responsible for the flow control systems that blend all of the different chemical compounds in the various batches.
I did mention that he could only use one hand didn’t I, ‘how many do you need to operate a keyboard’ he says.

So single-handed Graham has worked full time in a technically demanding environment on a self-employed basis, paid off his mortgage, put his kids through further education and into employment, topped up his own professional qualifications at night class, held down a top job for 17 years despite crippling MS and is the most positive and courageous person I know. I think I might just be quite proud of him.
Oh and how did this story start? ‘Just getting up and going to work’
Well that’s nothing at all, unless you’re the Carer of course.

Phil Jones is Chairman of the Board at NHS Dumfries and Galloway. 

Lies, Damned Lies and Statistics…? by Penny McWilliams

The use of general anaesthetic for extraction of children’s teeth has reduced very considerably in Scotland in the past 20 years – quite right too, I’m sure most people would agree.

The Scottish government has arguably led the world in funding the Childsmile programme, which is intended to tackle the fundamental causes of poor oral health in children as early as possible, by providing multiple educational and preventative interventions in community and school settings.

Like most large scale health programmes and initiatives these days, it is accompanied by HEAT targets, one of which is for a reduction in the number of elective hospital admissions for tooth extractions for children aged under 3 years.

All very sensible and intuitive, and given the scale of the funding associated with Childsmile, it is hardly surprising that the impact on oral health should be monitored over time to see if the various initiatives have been effective. It would be fair to say that dental public health experts worldwide are interested in the long term success or otherwise of Scotland’s Childsmile project, to see if they should commissioning or implementing something similar. Changing people’s behaviours as opposed to increasing their levels of knowledge is notoriously difficult; looking back on issues such as smoking and drink-driving, we all know that changes have gradually occurred, but they have taken decades of health education and health promotion effort to bring about.

The much improved access to dental care across D&G region since the mid-noughties, combined with the Childsmile activities by dental primary care and health improvement teams have been very successful in identifying those families most at risk of poor oral health. And we are much more successful than previously at providing appropriate dental treatment for young children with active tooth decay.

So paradoxically, the average age of many children’s first contact with a dentist has almost certainly come down, as many families now register with a dental practice for care. And the numbers of children aged 3-5 years being admitted to hospital for tooth extractions under general anaesthetic has certainly come down since 2003 rather than gone up, as the graph shows.

Chart 1 – DGRI Hospital admissions for tooth extractions in children aged 0-5 years old in 2004, 2009, 2013, and 2014 

But as you can see, the actual numbers of children under three admitted for tooth extraction are very low – only a couple a year on average. And some of these need an extraction because of trauma i.e. an accidental fall has damaged their front teeth, rather than tooth decay. And the average numbers admitted per annum have not really come down since 2009.

Very young children with painful tooth decay often now have much earlier contact with healthcare staff who successfully identify that they have dental treatment needs.

And those children for whom a tooth extraction is genuinely required, which can usually only be achieved by admission to hospital and use of a general anaesthetic, are arguably now more likely to get referred promptly.

If the whole point of HEAT targets from a government perspective is that ‘what gets measured is what gets done….‘ , where does that leave us when it comes to trying to achieve this particular target?

One way to achieve the HEAT target would be to leave the waiting times for admission long – children might be under three years old at the time of the decision to extract the tooth, but even with 18 week waiting time guarantees, most of them will be over three years old by the date of admission. Should we postpone provision of treatment in hospital for young children needing tooth extractions, because it would help us achieve the HEAT target? I don’t think anyone would advocate that, but could failure to achieve the reductions in numbers of hospital admissions be used to imply that oral health is not improving in Dumfries & Galloway region? Or NHS Dumfries & Galloway is not implementing the Childsmile programme properly?

We have already created local care pathways to ensure that the alternatives to extractions of deciduous teeth are available for young children, including active dental prevention strategies, and provision of more specialised paediatric dental treatment services. And because the risk associated with the use of general anaesthetic is very much higher than for routine dental treatment, dental general anaesthetic services are delivered in accordance with all of the currently available clinical guidelines, in as safe an environment as we can achieve.

I think it was Winston Churchill who talked about ‘lies, damned lies and statistics…’ and looking at the available figures general anaesthetics for dental extractions in children and Dumfries & Galloway over a period of years is pretty complicated. You can make an analysis of the statistics apparently illustrate almost anything you like.

Chart 2 below shows child admissions for general anaesthetic for dental extractions across Dumfries & Galloway region by quarter for 2013-14, arranged by age group. 

I could certainly argue for hours about what the figures and any mapping of overall trend does or does not tell us, based on this.

I’m sure that the original intent of the HEAT target was to see if oral health in very young children improves over time, particularly as it is well-known that children with complex physical, medical and social needs are at much higher risk of developing tooth decay. One can also assume it was intended to ensure that health authorities commissioned adequate local primary care dental services for families with young children.

But HEAT targets are very high-profile reporting measures, and failure to achieve them can very easily be misinterpreted, even by people who are entirely sincere and well-intentioned. Whatever the reasoning behind it, this one could become an unfortunate example of the misuse or misinterpretation of statistics.

Penny McWilliams is Director of Primary Care Dental Services for NHS Dumfires and Galloway

Communication and Handovers – What’s all the talking about? by Barbara Tamburrini

After 2 years and 99 posted blogs, addressing 68 different subject areas, I appear to have inherited the slightly daunting task of writing blog number 100 for dghealth. In that very first blog on 19^th March 2013, Ken Donaldson encouraged us to open our ears, embrace and not be frightened of communication, interaction and feedback between service providers and service users.

Ken’s vision for the future was to achieve “one blog a week from dghealth for a long time to come” and the evidence that this has been met is clearly demonstrated in the widespread engagement, diverse variety of subjects and immense learning that these blogs have generated.

Despite so many differing categories being listed for these blogs, communication is arguably a subject more frequently visited than most and this topic intertwines into every aspect of our professional practice and service delivery. Communication is an area where the effectiveness of its application has a direct impact on the outcome. We have all had situations, both professional and non-professional where ineffective communication has had a negative impact on our experience and when this involves healthcare provision, the effect can be profound.

One essential aspect of clinical communication involves handover and with the publication of NHS Dumfries and Galloway’s new handover strategy, there is an increasingly important focus on this fundamental area of care provision.

NHSDG is leading the way nationally in this area with the formation of a dedicated handover group to support, guide and encourage improvement work relating to handovers.

Furthermore, the senior endorsement of handover as a key area within NHSDG and the addition of this to our 9 point of care priorities has demonstrated that handover improvement work has significant support and advocacy at all levels throughout the organization.

But how do we improve the quality of handovers whilst maintaining our focus and energy on all the other priority areas competing for our professional attention? We work in an environment that can sometimes feel like we’re on a hamster wheel without the money to upgrade to first class travel!

Despite these challenging times, making tangible improvements in our work environment is easier than we might think and this is no less applicable to developing our approaches to handover. Asking 5 simple questions provides the structure required to build a foundation for improvement in handover practice.

 

1. WHO – who should be involved, who are our essential attenders?
2. WHEN – when should our handover take place?
3. WHERE – Where should this handover happen?
4. HOW – How are we going to structure this handover?
5. WHAT – What needs to be handed over?

Developing a local protocol for your department based on these 5 standards allows the identification and development of areas of handover whether they relate to shift handovers or transfers of patient care and the effect can be significant.

The protocol clearly identifies fundamental, locally specific details such as which personnel are essential to making the handover fully effective and the appropriate location and time of the handover being addressed. The manner in which the handover will be undertaken is also outlined and the details that need to be included are prioritized. An appendix can then be added to highlight the structure to be applied to the actual handover procedure and this standardizes the process by ensuring transparency and consistency with the way the handover is undertaken on a continual basis.

Over the last 6 months, the Hospital at Night (H@N) ANP team, based in DGRI, have been developing and enhancing their handover process beginning with the handover from dayshift to nightshift at 2145 hours and evaluation of this work is demonstrating impressive results.

So, how have we achieved this? We initially identified that the handover we wanted to improve was the nighttime meeting at 2145 hours since evidence has indicated that this represented a period of increased significance when care is transferred from dayshift to on-call teams. We then began by formulating a H@N handover protocol based on the 5 handover standards and we identified our target as being 95% compliant as indicated in the NHSDG handover strategy. We then used this local protocol to guide our development of essential elements such as the handover procedure and our improvements measurement.

During this time, we also evaluated our baseline position so we could clearly measure effectiveness and areas for improvement. Once our new handover protocol had been developed and finalized, we set implementation and review dates, publicized the improvement project and undertook team education before implementing and measuring the project.

Although the achievements we have been able to make are clear, we still have challenges in meeting our 95% compliance target in some areas, namely our attendance by essential personnel (WHO) and our punctuality (WHEN). Additionally, this work highlighted that whilst we could measure the handover procedure itself, we had no measurement process for the quality of clinical information handed over and this was felt to be an area of significant concern.

Therefore, the team has developed a quality measuring score for patients handed over using an SBAR-R format which was adapted from an SBAR scoring system implemented within the day surgery unit in DGRI. The aim of this H@N SBAR-R quality score is to measure the quality of clinical communication as well as guiding practice and providing a communication structure. It is also anticipated that this SBAR-R quality measurement can be used to underpin multidisciplinary training and education in relation to clinical communication.

This has definitely been a work in progress and as happens with all improvement work, successes are achieved whilst challenges are also experienced.

Initial and ongoing engagement has been crucial to delivering the improvements demonstrated and this will also be vital in addressing the challenges which still remain. Nonetheless, the handover improvements the H@N team have implemented and achieved, are easily transferrable across any specialty, discipline and clinical area. This presents the opportunity for shared learning and collaboration to assist and encourage areas who may be considering similar improvement work and practice developments across NHSDG.

The H@N ANPs have some challenges ahead to achieve 95% compliance in all 5 standards whilst also implementing quality measurement for handover communication but this is innovative work that we are proud to be sharing. With support from senior management, the improvement team, the handover group and clinical staff, the H@N team is able to progress these developments and participate in an exciting project that NHSDG is leading the way on nationally. It is hoped that data collection will continue to demonstrate the value of this work and its benefit upon delivering safe, reliable, effective, patient-centered care.

After all, isn’t that what we are all here for?

 Barbara Tamburrini is an Advanced Nurse Practitioner for NHS Dumfries & Galloway

 

 

 

 

 

 

“Here to Help” by David Johnstone

“Hello, how are you today? Is there anything I can help you with?”

These simple but effective words had an instant affect on me. They came from a teller as I entered a bank – of all places! – in Australia.

Whilst I didn’t need any help, it got me thinking about our channels of communication with people we serve here at NHS Dumfries and Galloway.

Only recently, hospital managers in Acute and Diagnostics took forward a pilot to make themselves more visible at the front entrance of DGRI.

What did this achieve? (I hear you say!)

Rather than waiting for you – patients, visitors and staff – to come to us, we took a proactive approach and decided to go out to you.

It goes without saying that too often all of us get caught up in the day-to-day jobs and diary commitments that it is too easy to lose sight of what we are actually here for. That is to deliver high quality, person-centred care and treatment for all who access our health services.

Over a week, we scheduled time in the diary for us as managers to stand at the front door and listen to what people have to say.

By showing a visible presence, we were met with a constant flow of real time feedback from those coming in and out of the hospital. There was positive praise for individuals and teams in the hospital which was directly fed back to staff. We also dealt with families worried about loved ones and in need of direction and support. We were able to deal with the situation there and then. Feedback gathered included:

• very positive feedback at Accident and Emergency, Ward 10 and 7. The standard of care is excellent
• A 92-year-old patient had a positive experience in Ward 16. She loved the food!
• Patient and family gave good feedback about care delivered in Ward 18. She said: “Canny fault the hospital.”
• Patient commented that Ward 16 was very busy but the care was very good.
• Person commented the wards were gleaming and were very clean and tidy.
• An elderly couple commented on the lack of parking facilities
• It was noted that some visitors were not using hand gel when going in and out of wards
• It was said the ‘staff are brilliant and you couldn’t ask for a better place to work.”

 

Mr Whitelaw went to Berlin recently to see how our European counterparts deliver health service. As he entered the German hospital, he was met with a trained nurse who was there to help. Again, the impact was extremely positive. There is no opportunity for feedback and complaints to get lost. Things are dealt with in real time, face-to-face.

We are all aware of how important patient experience is and the challenges that we must meet to deliver on targets set by the Scottish Government. Reflecting on my own experience from the pilot it has confirmed how we all, no matter what level of the organisation we are at, have a responsibility to listen and help.

It is perhaps good timing, especially as we start the ball rolling on how we want the inside of the new hospital to work. We are now developing a sustainable approach to ensure our managers are constantly visible. For my part, I am involved in recruiting new nursing posts at the moment and I very much plan to ensure that the ‘Here to Help’ approach comes as standard.

If each and every one of us – especially “the management” – ring-fenced some time to help the people we are here to care for, can you imagine the message this sends out?

David Johnstone is Lead Nurse for the Acute and Diagnostics Directorate at NHS Dumfries and Galloway