Cutting the Sugar…. by Fiona Green

Over the last 2 years NHS DG have been offering a structured programme of work experience to young people in their final years at school thinking about a career in medicine. This has been very well received by the young people who attend and the success of the programme is largely down to excellent organisation and communication skills of Anne-Marie Coxon and her team in the education centre who arrange tasters in various areas of medicine including medical admissions, theatre, surgery and A&E along with some time with me in the diabetes centre

Linocut by Hugh Bryden Crichton Hall- home to the Dumfries Galloway Diabetes centre

As a clinician it has been really interesting to spend time with these young people who have yet to develop preconceived ideas about healthcare and for me to try and understand what it is that excites them about spending a lifetime in medicine and to try and remember what it was that motivated me to apply for medicine and ultimately what made me move into Diabetes and Endocrinology.

For those of you who know me you will have heard me say that it is diabetes that excites me rather than the rare and esoteric conditions that I deal with in the endocrine service but I recognise that despite my real enthusiasm and commitment to improving care in diabetes that when these young work experience students come to diabetes clinic I sometimes find myself apologising to them that I don’t have any exciting procedures to show them, or new diagnoses to make; in fact in diabetes clinic I rarely examine people and I spend my time just listening to things that seem unrelated to sugar levels and talking…..

Just Listening and Talking…

The fact that I feel the need to apologise about the nature of diabetes clinic being  “just listening and talking” has made me realise  how little value we as hospital healthcare professionals place on these core skills that we all use every day. We are required to do mandatory training in many important areas such managing the deteriorating patient, infection control, awareness and fairness to name a few- yet it is possible for a healthcare professional to go through their in working career without any update, assessment or post graduate training in the core communication skills that we use every day. This lack of post graduate training in clinical communication skills is particularly apparent in the acute hospital setting compared to our colleagues in general practice and psychiatry where advanced post graduate training in consultation skills is the norm. Despite the seemingly acute nature of a hospital environment many of us spend a large part of our working week in clinics working with people to try and improve their health and wellbeing but what are we doing to ensure that these interactions are effective and meet the patient’s agenda?  Do we find it easier and quicker to pursue our own agendas and default into education mode rather that hearing about what is really important?  Several research studies have shown that by exploring a person’s background, worries and their understanding of their condition can help to avoid unnecessary investigations or anxiety for the patient as well as reduce the strain on resources[i][ii]

The success of the late Dr Kate Granger’s “Hello my name is …” movement and the “What Matters to Me” campaign show that in acute setting healthcare teams are beginning to contemplate a change to a more patient centred rather than the traditional paternalistic, didactic approach to our interactions with patients but this change is slow and these important initiatives are only an entry level to improving our communication with the people we see in clinic and reaching a shared agenda.

Locally Jean Robson and her colleagues from psychology, human resources and other interested clinicians have recently worked hard to put together a directory of diverse courses and programmes which are delivered locally by NHS Dumfries and Galloway aimed at improving advanced communication skills including sessions on communication skills which allow individuals to film and review their performance in real life clinic setting (been there and done that -daunting but very helpful), communicating with people with existing communication difficulties, human factors training and sessions on communicating with colleagues in meetings to name a few

So, back to the title of “cutting the sugar”. The discovery of insulin almost 100 years ago is one of medicine’s most remarkable discoveries changing the outcomes for people diagnosed with type 1 immeasurably as the before and after pictures below poignantly demonstrate

December 1922

February 1923

 

 

 

 

 

 

 

 

 

“Child 3” before and 3 months after insulin treatment

There is of course a but; insulin is not a cure for type 1 diabetes just a treatment and Insulin treatment brings with it a huge burden for the person with type 1 diabetes- blood testing more than 4 times a day, injecting insulin at least 5 times a day, assessing the carbohydrate content of foods are all required to achieve the tight blood sugar targets required to maintain health and wellbeing. This all needs to be balanced against activity levels and avoidance of hypoglycaemia. People with diabetes can never have a day off.  They become experts in managing their blood sugar levels and this brings me to the “just listening and talking bit”. Listening to what’s important to people when I’m clinic seemed more time-consuming in the beginning but by encouraging this shared understanding I have come to recognise that almost universally people with type 1 diabetes want to be healthy and that they fully understand the importance of controlling blood glucose but what I also now appreciate more clearly is that there are many other things that get in the way of achieving this goal. Some of these barriers to change seem obvious e.g. fear of hypoglycaemia, fear of injections but others may take gentle probing to identify e.g. the young woman who removed her insulin pump because she had a new boyfriend who didn’t know she had diabetes, the young mum on her own putting her own health after the needs of her family. Through training, practice and reflection I have come to learn is that each person is different and whilst a particular solution may work for one person it might not work for the next and whilst the temptation is for me to offer the solutions that I think will work by practicing the skills I have learnt at various communication skills sessions I now recognise that solutions generated by the person with diabetes are far more likely to be successful that anything that I may suggest. Of course very few consultations are perfect and like every skill we use practice, reflection and additional training can help us to improve which is why I believe that consultation and communication skills shouldn’t be seen as just “the icing on the cake” but more of the “meat on the bones” of our daily work.

Dr Fiona Green is a Consultant in Diabetes and Endocrinology at NHS Dumfries and Galloway

[i] Heisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA (April 2002). “The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management”. J Gen Intern Med. 17 (4): 243–52. doi:10.1046/j.1525-1497.2002.

[ii] eisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA (April 2002). “The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management”. J Gen Intern Med. 17 (4): 243–52. doi:10.1046/j.1525-1497.2002.

Why wont MY ‘thing’ go viral? by Ros Gray

Dreams are made when your great idea gets out there in this social world and goes viral. The very thought that thousands of people (likeminded as you) are looking at your good idea and thinking – “That’s a great idea, I could do that”
especially in our health and social care world when it isn’t necessarily the idea that’s new (although sometimes it is) but the ability to engage others to get them to follow your lead, for the benefit of patients and families.

So when things take off in this way, is it just good luck, or is there something we can learn? How does a good idea move from being MY great idea to something that a lot of other people want to do too?

In his New Yorker article ‘Slow ideas’ Gawande started my thinking on this topic (and a million other things!) when he discussed the evolution of surgical anaesthesia compared with the uptake of antiseptics to prevent sepsis. He described how the former spread almost worldwide in 7 years, the latter taking more than 30 years (and you might argue that the inability to clean our hands consistently even today means that we still haven’t cracked it).
It’s easy to imagine the difficulty undertaking any surgical procedure on a patient not anaesthetised (not least for the patient) – having your colleagues hold down the poor patient until such time as they (hopefully) passed out with the agony of the ordeal. Then you hear of an innovation where the patient inhales a gas and goes gently to sleep, allowing the procedure to be done with ease – a no brainer in terms of its likelihood to be adopted by others… and swiftly! The action of holding down the screaming patient and wrestling to undertake the procedure was clearly very personal and real for all those present.
However, the use of antiseptics to prevent an infection that the practitioner might never even see personally, leaves a lot to the imagination and limited personal cost, with the exception more latterly of professional reputation and in some quarters accreditation.
This situation was also exacerbated by the unpleasantness of the environment, where the practice of good antisepsis in the early days meant that theatres were gassed with antiseptics, hands scrubbed raw with early chemicals – all to prevent something that the practitioner might never witness… Perhaps, then, it’s easy to see why that adoption took longer than 30 years. Or is there more to it than that?

Gawande’s article goes much further and is very thought provoking but he fundamentally sets out how, if we want our ‘thing’ to be taken up by others at scale, then “…technology and incentive programs are not enough. “Diffusion is essentially a social process through which people talking to people spread an innovation,” wrote Everett Rogers, the great scholar of how new ideas are communicated and spread.”
He goes on to say that while our new social world can get the ideas out there
as Rogers showed, “…people follow the lead of other people they know and trust when they decide whether to take it up. Every change requires effort, and the decision to make that effort is a social process.”

I think these might be key concepts for us to consider with our personal improvement efforts. How hard do we make it to do the right thing?

Looking around at some other recent great ideas gone viral that I have become aware of – I thought it might be helpful for us to take a closer look at these and consider their spread from this perspective – I thank Delivering the Future Cohort 11 for their help with my developing thinking #DTFcohort11.

And also to consider how would the business world more broadly consider this issue?
Great marketers certainly start with two concepts that absolutely relate to our world and reflect Gawande’s thinking:
Know your audience
and
Make an emotional connection.

So looking at 3 examples of great ideas that have gone viral a little closer to home, can we identify the critical success factors that made them work so that we can apply that learning to our own work?

Case 1 – What matters to me

Who	Jennifer Rodgers @jenfrodgers Lead Nurse for Paediatrics NHS GG&C
What	What Matters To Me (WMTM) WMTM is a 3 step approach 1 Asking what matters 2 Listening to what matters 3 Doing what matters
Why	“Clinicians, in turn, need to relinquish their role as the single, paternalistic authority and train to become more effective coaches or partners — learning, in other words, how to ask, ‘What matters to you?’ as well as ‘What is the matter?’”
Where	Yorkhill Children’s Hospital Glasgow – global
When	Last 4 years
How	Originally Jens’ Quality and Safety Fellowship project, building on the concept of Lauren’s list in the USA; national and international presentations, Used the Model for Improvement as the improvement method. Started by asking one child to draw what mattered to them, and staff making every effort to include and react positively to this information –  now used routinely as part of the paediatric admission process. Spread includes other specialties such as the Care of Older People and those with Dementia.

Case 2 Hello my name is…

Who	The sadly very recently deceased Kate Granger (http://hellomynameis.org.uk @grangerkate) a young doctor battling at the time with terminal cancer, made observations about the human interactions she was struggling with at a very vulnerable time.
What	Kate decided to start a campaign, primarily using social media initially, to encourage and remind healthcare staff about the importance of introductions in healthcare.
Why	She made the stark observation that many staff looking after her did not introduce themselves before delivering her care. She felt it incredibly wrong that such a basic step in communication was missing. After ranting at her husband during one evening visiting time he encouraged her to “stop whinging and do something!”
Where	NHS England – Global
When	Last 3 years
How	Twitter campaign initially – #hellomynameis has made over 1 billion impressions since its inception with an average of 6 tweets an hour. Kate has left an incredible legacy with #hellomynameis that will continue to impact positively for patients.

Case 3 The Daily Mile

Who	Elaine Wylie – Headteacher (recently retired) St Ninian’s Primary School, Stirling thedailymile.co.uk
What	The aim of the Daily Mile is to improve the physical, emotional and social health and wellbeing of our children –regardless of age or personal circumstances.
Why	It is a profoundly simple but effective concept, which any primary school or nursery can implement. Its impact can be transformational- improving not only the childrens’ fitness, but also their concentration levels, mood, behaviour and general wellbeing.
Where	St Ninian’s Primary School, Stirling – global
When	Last 3 years
How	The Daily Mile takes place over just 15 minutes, with children averaging a mile each day. Children run outside in the fresh air – and the weather is a benefit, not a barrier.  There’s no set up, tidy up, or equipment required. Children run in their uniforms so no kit or changing time is needed. It’s social, non-competitive and fun. It’s fully inclusive; every child succeeds, whatever their circumstances, age or ability. Elaine demonstrated huge impact on eliminating obesity in her primary one class that had stated the Daily Mile in Nursery.

In each of the cases the idea started with one individual who had a simple, sensible, not necessarily unique idea, but certainly something that was a bit different from the status quo – perhaps even challenging and making the status quo uncomfortable.
Each leader had a degree of power and autonomy in their local context, for Kate this was as an informed patient, so some might argue her ability to influence would have been limited.
Each idea was simple and easy to try in different arenas.
Each was free or relatively low cost to implement, even at scale.
The impact on patients or children was obvious or in the course of early testing clearly demonstrated.
Each leader used social platforms as a spread mechanism.
In every case, the idea clearly feels like it was the right thing to do, or scandalous that it wasn’t happening routinely, something each of us would want to happen if we were the subjects in question. Perhaps even the standard we apply every day in our professional or personal lives and assume that everyone else does too.
So clear evidence to support Rodgers view that “Diffusion is essentially a social process through which people talking to people spread an innovation,” – Perhaps the easy access to social platforms in these cases made ‘people talking to people’ helped in these cases?
Each leader knew their audience and played to that strength – but also and perhaps most importantly in each case, the emotional connection is huge, but each from a very different perspective.
Is the emotional connection the critical success factor in these cases – and something we should consider carefully if we want our work to spread?
Which emotions might you tap in to when trying to engage folk in your great idea? Emotions described in pairs of polar opposites might give you some food for thought and a place to start with your great idea:
Joy or sadness
Anticipation or surprise
Fear or anger
Disgust or trust

You will have many more thoughts than time permits here, but I leave you with a thought of mine… perhaps we all have an opportunity to use a more considered approach to the scale up and spread of good intentions by learning from those that have done that well.
If not you, who? If not now, when?

Simple checklist
How simple have I described my great idea – Have I got my 1-minute ‘elevator pitch’ worked out to easily influence others?
Does it feel the right thing to do?
Is it relatively cheap or free? If not who will fund the idea, now and then at scale?
Am I convinced that it isn’t happening to every patient/family every time, reliably? Do I have the data that proves that?
Do I have the power to influence, or if not, who do I have to get on board?
Do I have the data and story to describe how it works and how easy it is to adopt, including the impact?
What social platform for spread will I use?
Which emotions are triggered, or will I aim to tap in to, in order to engage people to want to do things differently?

Ros Gray recently retired from her post as National Lead for the Early Years Collaborative. Prior to that post she was Head of Patient Safety for Healthcare Improvement Scotland.

 

Rights without responsibility… where are we going? by Anne Marshall

“Man must cease attributing his problems to his environment, and learn again to exercise his will – his personal responsibility.”
Albert Einstein

 

‘It’s not my fault.’

‘It’s not fair.’

‘I want that.’

‘Why should they get that when I can’t?’

 

Responsibility – one of those words with which no one much wants to associate these days, but a word that I believe lies at the heart of the change that is essential to sustaining not just the NHS through the 21^st century, but life beyond the 21^st century.

In his blog Ewan Bell asked how the NHS should prioritise its services – what are the essentials and what should we be doing?

I think we need to turn that thinking round and look at it differently – from the point of view of ensuring that as we empower people we also expect them to be accountable and therefore responsible for the choices they make. . . so here’s a few thoughts and a lot of unanswered questions!

The more society gives in terms of allowing individuals to renege on any personal responsibility and the more it protects them from the consequences of their actions and decisions the deeper into this complex and costly moral mire we sink.

So where do we start? Can we make the huge cultural shift required without some horrendous intervention such as war, which inevitably enforces change from selfish desire and want to more simple human need.

How do we teach people to take personal responsibility when they know they simply don’t have to take any because someone else will always pick up the pieces? How do we reduce escalating public expectation? The NHS cannot simply cut back on what it does while society as a whole continues to abandon all sense of personal responsibility; expects more and more to be done for it and litigious greed is ready to pounce on any perceived breach of human rights.

When prisoners win compensation for having the slop out their cells what hope is there of change? Don’t the rest of us have to clean our own toilets?

The fact that benefits are capped at £350 a week but someone on the minimum wage earns only £251.25 before deductions seems to be indicative of where we, as a society, are at. There are few or no consequences for failing to take responsibility. Add to this the fact that publically funded advice agencies actually complete forms for people and lie in order to get them certain benefits which they are neither entitled to nor need and you simply perpetuate perceived dependence, engendering more unnecessary demand and expenditure.

The problem is beautifully illustrated by the story of two students, aged 16 and 19 respectively, sharing a flat. The 16 year old gets her bursary and a job and puts some money aside for the summer months. Her wages fail to come through so she asks for support from the college hardship fund. She is entitled to nothing – because she has put a few pounds aside. The 19 year old blows all her bursary, litters the flat with takeaways and empty drink bottles, builds up a huge debt and gets handed out hundreds of pounds from the hardship fund . . .

Unfortunately the ending is not fair or just, or, more importantly in terms of the NHS, sustainable.

It reminds me of the story of the three little pigs and their houses built with straw, sticks and bricks. Two of the pigs learned their houses were not safe because they had to run for their lives from the big bad wolf and find shelter in the brick house built laboriously by their brother.

We have created a society where there is no big bad wolf – no consequences. We have created a society where people simply expect the state (be it NHS, benefits system, social services or whatever) to sort out all their problems and if they don’t many people either kick up a huge fuss, shout and scream until they get what they want or take on a lawyer.

So how do we start to change things and find that balance between a society that takes care of its vulnerable and needy and yet engage differently with those who are outside of the vulnerable and needy group but still think they have the right to whatever they want at whatever cost – as long as it is not to their pocket or life style.

How do we start to embrace the massive moral and cultural shift needed from politicians down and ‘minorities demanding the same rights as majorities’ up? How do we deal with the human rights bill which in its purest form is an excellent and necessary thing but which is so open to interpretation and abuse that it forms a rod for our own backs?

Answers on the back of a postcard please. . . !

“When you blame others, you give up your power to change.”
Unknown

Anne Marshall is a Staff Nurse on the Renal Unit at NHS Dumfries and Galloway

In Memory of Kate by @kendonaldson

Over the years compassion and kindness have been common themes on this blog and nobody encompassed them more than Kate Granger.

Kate was many things; Consultant geriatrician, campaigner, wife, aunty, MBE and patient. She was born and raised in Yorkshire and after qualifying in medicine from Edinburgh University returned there to complete her training in medicine for the elderly. She married the love of her life, Chris Pointon, in 2005 and then in 2011, at the age of 29, everything changed. After falling ill whilst on holiday in California she was diagnosed with a Sarcoma and given 12 – 18 months to live. Characteristically she decided to defy the odds and do something meaningful with the short time she had left.

I think it would be fair to say that prior to her illness Kate was a compassionate, caring and person centred clinician who inspired those around her. However her illness gave her a unique insight into how we deliver healthcare, in particular the ‘small things’ which we often forget – like introducing ourselves. It was during a hospital admission in 2013 that Kate noticed that none of the healthcare professionals dealing with her told her their names. The first person to do so, and show real care and compassion, was a porter. She reflected (and raged a little) about this and from that experience the #hellomynameis campaign was born.

#hellomynameis is a great example of a very simple idea which has the power to make a difference. It started on twitter and progressed to name badges, internet memes and finally circled the globe. During the Ebola outbreak in Western Africa those caring for the afflicted could write their name on a #hellomynameis sticker and attach it to their protective suit and thus patients would at least know the name of those tending them. Many politicians and celebrities have endorsed the project and it has been adopted in many countries around the world. I for one continue to wear my badge with pride.

We were very fortunate that Kate wrote for this blog in 2014 just prior to her visit to NHS D&G. Her blog can be read here.

Since Kate died I have read many obituaries and blogs which are far more thoughtful, and certainly more eloquent, than anything I can hope to write. I would like to quote a few of them here.

Ali Cracknell, a fellow Geriatrician and friend had this to say on the British Geriatrics Society blog:

“I always thought we would work together long term, and the thing that makes me really smile is Kate is with me more than any other person at work. Every encounter with a patient “hello my name is …”, every MDT, every meeting with a new member of the team and every morning I put on my “hello my name is” badge, she is with me, she is behind every little thing I do every day, that just makes such a difference. How could one person make a difference like that?  “#hello my name is”, is so much more than those 4 words, Kate knew that and felt it, and we all do, it is the person behind the words, the hierarchy that melts away, the patient:professional barrier that is lowered, the compassion and warmth of those words.”

Just Giving, the website through which Kate raised over £250,000, described 5 Lessons they learned from Kate. You can read them in depth here but the 5 lessons are:

1) We need to communicate
2) Always rebel
3) Remember romance
4) Make goals
5) It’s ok to talk about down days

A little more about number 3, Remember romance. Just giving had this to say about that…

“Kate and her husband Chris have set the bar high when it comes to romance. Throughout Kate’s journey, she never forgot to mention how important her partner is to her and how lucky she feels to have met her soulmate. After the diagnosis, the couple recreated their wedding day and renewed their vows. They even did their first ever date in Leeds all over again.
The duo did absolutely everything together, including competing in fundraising events.
Seeing Kate and Chris wine, dine and care for one another teaches us to never take our loved ones for granted, and to remember romance. The couple remained incredibly close and strong for the duration of Kate’s illness, and managed to maintain an amazing sense of humour in the darkest of
times. It reminds us all to reflect on how we treat our partners.”

The BMJ published a particularly touching obituary which can be read here.

I will end with a quote from Macleans, a Canadian weekly magazine…

“Jeremy, Jackie, Tasha, Lucy, Pam—Kate’s doctors and nurses had names in her blogs and Twitter feeds. Outliving expectations by three and a half years, she met her fundraising goal of £250,000 for Yorkshire Cancer Charity, encouraging doctors worldwide to say hello, as she herself said goodbye.
On July 23, 2016, on her 11th wedding anniversary, three days after meeting her fundraising target, Kate was lying in her hospice room, no longer able to swallow. Christopher opened a bottle of champagne and placed drops on Kate’s lips. Caretakers called in her other family members. At 3:50pm, after Adam and Christopher’s mother had arrived at her bedside, Kate stopped breathing. She was 34.”

 

 

Ken Donaldson is Deputy Medical Director (Acute Services) at NHS Dumfries and Galloway