What are you so scared of? by David Christie (@bagheera79)

“Now, what I want you to do is focus on your breathing. Slow big deep breaths, in and out. You’ll think nothing’s happening at first, then you’ll feel the world become a warm, fuzzy place. Maybe imagine yourself somewhere like a hot sunny beach, waves on the shore, warm sun… big deep breaths, in and out…”

I usually say something along these lines as I’m drifting you off to sleep for your operation. The wording and phrasing obviously varies, and to be honest it’s the tone of my voice that’s important. The aim is to create an atmosphere of calm and reassurance. Something to focus on instead of the beeping of the monitor and the plastic smell of the mask, and the thought of what happens next. It sounds daft, but it’s important. People can be terrified, when they come into theatre, truly terrified. 

Some of the reasons for this are obvious – perhaps the reason that you’re having surgery, such as cancer. Or the surgery itself carries risk – such as surgery to major blood vessels, the brain, the heart. But some of the reasons are a little less obvious, I think, and easily forgotten. Imagine you’re coming to theatre. Just getting to that point involves the co-ordinated effort of many, many different teams. Patients need to be referred, seen in clinic and booked for surgery. There’s a need to have pre-operative assessment done for all the medical, nursing, physiotherapy and social needs. A raft of co-ordinated investigations such as blood tests, ECG and more are ordered to make sure that we know enough about you to be able to do it safely. The booking teams need to create lists that need to match with the availability of the surgeon, the waiting time, the urgency of the surgery and the availability of the patient – and possibly that of your carers or relatives. The theatre team needs to know what particular bits of kit are needed and to have it ready for you on the day. Extra members of staff from different departments may also be needed – such as additional surgeons or radiography – the list goes on and on. The whole process is so enormously complicated and intricate that it astonishes me that it works at all. And it needs to have this level of complexity – we humans are not car parts, stamped out in a factory. There are so many different individual problems that need to be overcome, the system needs to be able to cope with them all. And, by and large, we do.

The downside of being able to cope with all of this with a high degree of safety is that the process has become streamlined, smoothed, tick-boxed and protocol-driven. The most widely publicised example of this is the WHO checklist. With a few simple questions this checklist manages two things that seem obvious but used to be done very badly. The first is that it requires all members of the operating team to meet, introduce themselves to each other, and discuss the day’s work ahead before anything happens. In one neat moment, suddenly everyone knows who everyone else is, what the plan for the particular patients that day is, and what problems are anticipated. The second is that, for every patient – before they’re sent off to sleep, is involved in a discussion that is designed to ensure we have the right patient for the right operation, and various safety aspects taken care of – antibiotics, crossmatched blood, prophylaxis against life-threatening blood clots… It’s simple, effective, and has saved many lives all over the world. Unfortunately, all of this can be hugely depersonalising, and worse, unsettling. Having a group of strangers discuss how much blood you’re possibly going to lose just before you fall off to sleep isn’t necessarily reassuring. The whole process of coming in early on the day of surgery – hungry and anxious – to be told to get undressed and meet a sometimes bewildering range of people, including a surgeon that might be different from the one you expected. To be repeatedly asked about yourself, and then to be discussed while you anxiously wait – no wonder people are scared!

So, what can we do? We only have a few minutes with each patient in the morning rush – but that’s enough. To engage with people on a human level, to let them know that we care, to stop them being quite so terrified is not as difficult as it sounds. Simply saying hello and telling people your name goes a long way – it says you care about them enough to let them know who you are! Tell them what’s going to happen and why, what to expect so that they don’t get a fright. Remember that the nonagenarian in front of you may have had an extraordinary life and seen more than you can ever imagine, don’t be patronising.

All of which brings me back to my little spiel at the top, there. Recently I was anaesthetising a man in his eighties for a straightforward urological procedure. He’d been telling us about his life, time in the mountains, his high-flying daughter, an severe accident he’d had racing motorcycles over fifty years ago. I started to inject the medicines to send him off to sleep, and talking about sunshine, warm weather – and he interrupted to say, “Nah, son. I’m gaunnae dream about scoring a penalty fir Liverpool, right in front of the Kop.” I loved that, it made me smile. It made everyone in the room smile, in fact. It reminded me anew, yet again, that our patients are people, with hopes and dreams and complicated lives, and to not lose sight of it. And it reminded me also, that no matter how old we get, boys never grow up.

David Christie is a Consultant Anaesthetist for Dumfries and Galloway Health Board

Leadership in a rewarding, complex and demanding world by Paul Gray (@PAG1962)

The people we serve – the people who live in Scotland, and visitors too – have high expectations of us. And so they should. We operate in a complex and demanding environment, but NHS Scotland is a successful organisation, delivering to high standards of timeliness and quality, and always seeking to improve. The people I meet work day and night, every day of the year, to deliver compassionate care, and whole range of ancillary and supporting services from health science to finance to laundry. And the rewards of speaking to someone whom we have been able to help, who expresses their thanks and wants to emphasise how much they appreciate the care they have received, can’t really be quantified.

Some facts and figures might help. What are we actually delivering each year, with a workforce of over 150,000, and a budget of £12bn, serving a population of 5,295,000?

  • Over 24 million GP and practice nurse consultations
  • Over 450,000 acute day case procedures
  • Over 1 million acute inpatient procedures
  • Over 1.6 million A&E attendances
  • Over 4.6 million outpatient attendances

And we have over 4.7 million patients registered with an NHS dentist, and real progress on improving oral health in children through the Childsmile programme. Pharmacy is developing too, with services being introduced including Minor Ailment Service (MAS), Public Health Service (PHS), Acute Medication Service (AMS) and Chronic Medication Service (CMS).

We’ve also made considerable and measurable progress on patient safety through the internationally recognised Scottish Patient Safety Programme. Our most recent data show a 16.1% reduction in Hospital Standardised Mortality Ratios since the implementation of the Scottish Patient Safety Programme in 2008; and cases of C.Diff in patients aged 65 and over are at their lowest level since monitoring began.

We are integrating health and social care, so that more people can be supported to stay at home, or in a homely setting – some of whom might be quite unwell, with complex conditions. That means different ways of working, with a range of partner organisations, while maintaining our focus on safe, person centred, effective care. And Sir Lewis Ritchie is leading a review of Primary Care out of hours services, which I am sure will offer some important recommendations on the way we structure and provide unscheduled care. The demographic trends we face are well known to us – we do have an aging population, with increasingly complex health conditions; and there is clear evidence that people generally have better outcomes, and are happier, when they can be cared for at home. Indeed, it’s worth remembering that although there is clearly pressure on General Practice, 87% of patients say that the overall care provided by their GP surgery is good or excellent.

When people do need to come to hospital, we work hard to treat them within the standards we have set, whether that’s to see and treat 95% of people within 4 hours of attending an Emergency Department, or to deliver treatment within our 12 week Treatment Time Guarantee. We’ve made considerable progress on getting to the 95% A&E target across Scotland and I’m grateful for that – but I do know that there are peaks in demand, and that patients are tending to present with more serious and complex conditions. And I know that some specialties are finding recruitment tough, which adds to pressure, but we should also remember that 89% of Scottish inpatients say overall care and treatment was good or excellent – which is highest figure since surveying inpatients began in 2010.

We continue to look critically at ourselves, through a combination of internal assessment and governance, and external assessment through Healthcare Improvement Scotland, and Health Environment Inspections. We don’t pretend that we always get it right, and when we don’t, we act systematically to understand the issues and to implement the changes we need to make with purpose and commitment. And we learn too from reports from elsewhere, like the recent report on maternity and neonatal services in Morecambe Bay, to which our Chief Medical Officer, Catherine Calderwood, contributed, and earlier reports such as those on Mid Staffordshire, including the report “A promise to learn – a commitment to act” to which our National Clinical Director for Healthcare Quality, Jason Leitch, also contributed.

Paul Gray 3So what does this mean for leadership in the face of complexity and increasing demand? What does it mean for leadership when often the external narrative – whether in print, broadcast or social media – focuses on problems, and gives less recognition to the things that are going well or improving? I offer the following suggestions. It’s drawn from my own experience of the things that have worked for me, so in that sense it’s personal. But I hope that it prompts you to think and reflect, or to have a conversation with someone. If it did, that would be great.

  • Ask yourself if you can describe what you do, and the outcomes you need to achieve, simply and clearly in a few sentences. If you can do that, it helps you and those around you to understand how they fit in to this complex world.
  • Remind yourselves and those around you of what we do well. Take time to recognise success and to praise a job well done.
  •  Build on what we have – almost all of the people I meet are proud of what they do, and want to do it better.
  •  Remember that leadership is about proactive actions, not job titles. Some of the best examples of leadership I have seen include:
  •  the porter who realised that a patient was upset, spoke to her about how she was feeling, made the staff on the ward aware, and got her a cup of tea. In her words, “He turned my day right round”;
  • the receptionist who realised from the questions asked by visitors that the signage somewhere in the hospital was misleading, went and found the misleading sign, wrote out some better wording and gave it to her colleagues in Estates.
  •  Be open to feedback. Seek it out – and don’t be afraid to reflect on what you hear. Don’t be afraid of external scrutiny either. It can be tough, even painful at times, but better to learn, improve and grow than to stagnate and provide a service that is less good than it could be, or to put patients at risk.
  •  Learn all the time. Encourage and support others to learn. Learn from the best, as well as learning from what went wrong.
  •  Have honest conversations. Don’t let issues fester until they create a real problem. Prepare for these conversations. Good conversations don’t often happen by accident.
  •  If there is an issue or a problem, describe it specifically, and think carefully about the best way to tackle it. Ask yourself if there’s a contribution you could make to the solution.
  •  Uphold the core values of the NHS. If you see or experience inappropriate behaviour, such as bullying or discrimination, speak up, or seek help to address the issue. Don’t let it slide, or suffer in silence.
  •  Think about what the complexity and demands mean for the people in your teams. Acknowledge the situation when things are difficult, or the going is tough. People appreciate honesty, and see through hyperbole.
  •  Ask people for their ideas about how best to tackle problems. They will have some amazing ideas – I promise you!
  •  Leaders take advice and ask for help. They know that they don’t know everything. They recognise and value that expertise that others have. So don’t become isolated, especially when times are tough.
  •  Involve others in decisions – especially in decisions that are about them, or affect them in some way.
  •  If you’re wrong, say so, and apologise. Be transparent. It’s not weakness to admit a fault or a mistake.
  •  Understand the people who work with you, for you and around you – including people who work in different organisations, who might have a different governance context, face a different set of pressures or demands, and use different language from that used in the NHS. They will appreciate that, and if you understand people and their motivations, it’s far easier to be influential. People are far more likely to listen to you if they know that you understand their perspective.
  •  Be someone who offers more often than they ask.
  •  Be someone who gives credit to others, and doesn’t seek it for themselves.
  •  Be persistent and methodical – if something is right, don’t be deflected by setbacks and criticism. If you have considered a course of action carefully, listened to advice, and considered the evidence, follow it through. In a complex world, people value leaders who keep a steady course, and don’t chop and change every day. However, if the context or the evidence changes, review your course of action. Persistence in the face of adversity is good leadership. Dogged pursuit of an outmoded idea isn’t.
  •  Look after yourself. Build and develop networks of people you can consult and talk to when the going gets tough. Take time off, and take a bit of exercise. Make time for family, friends, and things you enjoy outside work. Easy to say, I know – but we do need to restore our energy and keep our perspective. We give our best when we are at our best.

Paul Gray 1And finally – a big thank you from me. I am both proud and humbled to be associated with NHS Scotland. I am proud of the work we do, and of the people who do it. We have a great privilege to serve patients, their families and their carers, and a strong and shared commitment to do it well.


Paul Gray is Chief Executive Officer for NHS Scotland and Director General Health and Social Care, Scottish Government.


‘Walk a mile in someone else’s shoes…’ by @Rosgray

Ros G 1

I remember reading a paper a few years ago now that said (something along the lines of) when thinking about the strategic direction of your organisation, you can focus on customer needs and experience, or you can focus on staff needs and experience. It doesn’t matter which, as long as you focus on one, as the quality of the service you deliver will improve. You just need to focus!

As a staff member I get the point, and as someone who works for the public sector it also feels right to put our focus on the needs of our customers.

So there is a lot of conversation in health and social care just now about the concept of asking patients and others “What matters to you?”. It is generally agreed that it can help us understand their needs and maybe understanding of the position they find themselves in under our care. In some cases it has fundamentally redefined the way the service is delivered and often in ways that health care teams might never have dreamed possible.

Ros G 2The newest Scottish hospital has integrated a systematic approach to delivering ‘what matters to me’ for every patient…


But all this got me to thinking – if I was a patient today, what would I put on that board?

I have a small family, a daughter’s wedding imminent, I am an only child so no major significant others to accommodate, so I guess they would need to be on there.

But what else would I say?

Reflecting on a fairly recent hospital admission, I had great confidence in the clinicians (a given…) I wasn’t so confident about hand hygiene; I wasn’t eating much so I was really interested in getting hot soup…

Ros G 3So would my WMTM board say – that your hands are clean (and show me how); I like my soup hot; and ask me about my mother of the bride outfit?


But the important thing is that it would give us the opportunity to explore what was underneath those words and begin to consider the differences between asking ‘What’s the matter’ and ‘What matters’ and to understand the patients concerns and goals for clinical outcomes and managing life limiting, long term or indeed any conditions.

Ros G 4

Some say you absolutely cannot walk in someone else’s shoes. Our history makes us who we are; our perspectives, our successes and failures, our experiences. We cannot put ourselves in someone else’s position in exactly the same way, at best, we can be open, to listen and truly hear, to get more information and be better placed to understand and be prepared to do things in a different way.

And that can be tough.

It can be tough on us as professionals trying hard to deliver a service in increasingly challenging times.

But I suggest it might also be rewarding, bring back the reason we went into this kind of work in the first place, and make that work more enjoyable, knowing that we are engineering a different approach to care delivery that is focused on what matters to our patients. Delivering the care to them as we would the ones we love.

So let me leave you with time to reflect…

What would be on your ‘What Matters to Me’ board?

How will you develop ways to ask your patients about what matters to them?

And how will you use that information to deliver the service differently for them and others in the future?

Because that could be you and yours…

While I accept we cant walk exactly in someone else’s shoes, some of our healthcare colleagues in the USA have attempted to open our eyes a little with this short video.

‘Could a greater miracle take place than to look through each others eyes for an instant?’ Henry David Thoreau


Ros Gray is Head of the Early Years Collaborative for the Scottish Government