Can I make a difference? by Paul Gray

It’s a big question – can I make a difference?  How does it feel to ask yourself that?  For some of us, the answer will be different on different days.  My experience suggests that your answer depends much less on what you do, than it does on how you feel.  In this blog, I’d like to offer some thoughts on making a difference.

However, some context first.  I fully recognise the challenges we face.  Health budgets are going up – but pressures on recruitment, and the demands of an aging population, are also very real.  There is also still much to do in tackling inequalities, and improving the health of the population, which NHS Scotland can’t do on its own.  And we do know that people have the best outcomes when they are treated and cared for at home, or in a homely setting.  So our current models of care are transforming to meet these demands, and to provide the most appropriate care and treatment for people, when they need it, and change brings its own challenges.

So my first suggestion is to turn the question, “Can I make a difference?” into a statement – I can make a difference.  If you start from that standpoint, you’re much more likely to succeed.  It’s easy to become pre-occupied with the things we can’t change, and the barriers and problems – I know that I fall into that trap from time to time.  But wherever I go, I see people throughout the NHS, and in our partner organisations, making a difference every day.  So ask yourself, what is the one thing I can do today that would make a difference?  And then do it!

paul-1Now, give yourself some credit – think of an example where you did something that was appreciated.  Write it down and remember it.  If you’re having a team meeting, take time to share examples of things that the team did, that were appreciated by others.  Sharing these examples will give you a bank of ideas about simple things that matter to other people.  And it also gives you something to fall back on, if times are tough.

Next – think of an example when someone did something for you, which you appreciated.  Find a way to share these examples too – if it worked for you, it might work for someone else as well.  Ask yourself when you last thanked someone for something they did well, or something you appreciated.  It’s easier to go on making a difference if others notice what you’re doing!

If you’re leading or managing a team, ask yourself how much time the team spends discussing what went well.  It’s essential to be open and transparent about problems and adverse events, but if that’s the whole focus of team discussions, we overlook a huge pool of learning, resources and ideas from all the positive actions and outcomes.  And we risk an atmosphere where making a difference is only about fixing problems, rather than about improvement.  So, as yourself and your team, what proportion of time should be spent on what went well?

Remember to ask “What Matters to You?”.  I know that the focus of this question is on patients, and that’s right because they are our priority, but it’s a good question to ask our colleagues and our teams as well.  Just asking the question makes a difference – it gives you access to someone else’s thoughts and perspectives, and is likely to lead to better outcomes.

paul-2Will any of this change the world?  Not on its own, of course.  But you could change one person’s world, by a simple act of kindness, or listening, or a word of thanks.  You can make difference!

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

Honest Reflections by Barbara Tamburrini

As this is now the third blog I have written for DGHealth, either there is a shortage of ‘willing volunteers’ or others have found better ways to say “maybe, possibly, perhaps soon” to Ken Donaldson when his charming request drops in the email ‘in-box’. Whatever the reason, I find myself agreeing to contribute and construct another brief moment of interest in our increasingly busy days. Having written previously about handover processes and the importance of good communication, I thought I would flip this on its head for this blog and consider the ‘inward’ communication reaching our ears from eager and sometimes over-active media sources and outlets.

A scan of headlines published over recent times don’t make happy reading for hard-working and dedicated NHS employees trying their best to simply ‘stay afloat and fight the fire’. Over the last 4 days, a number of reports sum up the general gist of current NHS news:

  • 9th Feb 17 – “Worst A&E waits ever, leak suggests” – BBC News
  • 8th Feb 17 – “The NHS and its crisis: Myths and realities” – Sky News
  • 7th Feb 17 – “Scotland’s A&E departments miss key waiting time targets over festive period” – Daily Record
  • 7th Feb 17 – “Maternity services in Scotland ‘beginning to buckle’” – BBC News
  • 7th Feb 17 – “Ageing UK midwife workforce on ‘cliff edge’, warns RCM” – Nursing Times
  • 7th Feb 17 – “NHS [Scotland] cancels 7740 operations due to lack of resources” – STV News
  • 5th Feb 17 – “Scotland patients waited more than a year for hospital discharge” – Sky News
  • 5th Feb 17 – “Revealed: The hidden waiting list scandal for Scotland’s NHS” – Sunday Post
  • 5th Feb 17 – “Growing waiting times threat to NHS” – BBC News

The recent coverage by the BBC assessing the state of the NHS across the UK in their NHS Health Check Week raised issues including a perception of desperate times inside A&E departments, analysis of patient flow reducing to a halt and “clogging up” hospital wards and frontline services being radically changed in attempts to overhaul health provision in the wake of the publication of NHS England’s five-year plan for the NHS in 2014. Indeed, as recently as 15th January 2017, chair of the BMA, Dr Peter Bennie was quoted as stating the Scottish NHS was “stretched to pretty much breaking point” and “heading for a breakdown” unless the government acknowledge the disparity between the current comprehensive service provision and existing funding levels.

So what does all this mean for humble workers ‘at the coal face’ and patients who so desperately rely on the NHS and our contribution within it? Dr Bennie wisely points out that honesty is required when assessing all elements of our much loved but potentially deeply troubled NHS. Honest reflection on our actions and behaviours as NHS staff is required to ensure we are all maintaining a focus firmly centred on our patients and clients. In a profession which is becoming more and more challenging with morale which seems to be ebbing lower and lower, can I really state with certainty that my focus is always upon my patients?

If I am looking at my last shift on duty, as part of the DGRI capacity team, I know that the greatest majority of my time was spent considering patient care but, the complexities of the work involved in capacity management mean a constant ‘juggle struggle’ between complicated discharges, patients keenly attending for their long-awaited surgery and fast and furious emergency admission rates with significant staff shortages thrown in to make life really interesting. This is a really difficult environment to function effectively, positively and proactively.

Its exceptionally difficult to have to say “I’m really sorry but I don’t have anyone who can give you a hand at the moment” to hard-working and struggling colleagues whom you respect and want to help. This inevitably influences work-focus and morale, sometimes away from patients and onto less fruitful, less important areas – we’re only human after all! I’m sure many of you reading this blog can identify with this and acknowledge that there can be times when we recognise that our concentration has slipped away from the real reason we are all here. This honest reflection is being actively encouraged in nursing through the revalidation process which will positively impact the profession in the future with a similar process in place for medical staff.

Honesty is also required from patients and clients using NHS services with individual ownership of health and the impact of lifestyle choices upon this of fundamental importance. The vast majority of NHS patients freely and actively claim this responsibility but this is not always the case in some crucial clinical areas like Emergency Departments. For the headlines to stop, the public also need to do their part. In a recent article in Glasgow’s ‘Evening Times’ (9th January 2017), it was stated that around 1 in 6 Scottish ED attendances may be unnecessary at a potential cost of £33 million and whilst ministers have provided responses aimed at removing any punitive element and reassuring the public that they are right to be concerned about their health, this concern needs to be correctly channelled for current pressures on health services to be eased. Patients with 3-month history of injuries, minor ailments which could be assessed elsewhere and those telling us they didn’t bother trying their GP as “they wouldn’t get an appointment anyway” are all too frequent presentations in busy ED’s. In my ‘other role’ as an ANP in ED, every time a patient told me this, I called the surgery myself and was given an appointment that day for their patient so, as well as accepting ownership of their own health, patients and service-users also need to be well-informed, confident and comfortable about the health services they access and when they utilise these valuable resources.

My feeling is that an organisational honesty also exits within current healthcare with ‘the powers that be’ having a responsibility to consistently and carefully examine the healthcare delivered with rectitude and reliability. We are somewhat fortunate in that we have an organisation who actively engages with staff through measures such as #ontheground, weekly core briefings, active and lively facebook and twitter accounts and the informative and interesting DG Change website (http://www.dg-change.org.uk). Indeed, this weekly blog also serves as a useful interactive communication with reflections and comments on posts actively encouraged. But is this enough? I would argue that even though these proactive measures exist in NHSDG along with many other approaches, staff morale remains low in some clinical areas and sickness absence rates are running well above optimum levels in some departments. So, are the current measures of engagement between the organisation and its employees inaccessible, uninteresting or unimportant to some staff, not effective enough, not addressing the correct issues or simply not delivering the desired impact? Although impossible to answer within this blog, the significance of this question and the consequences associated with it, must remain high on the agenda if staff empowerment, engagement, motivation and morale are to be maximised as we hurtle head-long towards a new hospital and evolving chapter in our healthcare provision.

Every ward I go in to during my capacity shift has AHP’s, nursing and medical staff who look tired, strained and burdened by an ever-increasing workload with constant financial and resource pressures making the job all the more difficult. But, and this is crucial, staff continue to come to work to do the best job they can given these constraints. They continue to change rota’s to cover absences, work through breaks and past finishing times to help their colleagues and patients and they continue to ‘fight the fire’ with dedication, sometimes in the face of adversity. Healthcare staff MUST care about the service they provide, to deliver care which remains meaningful, appropriate, safe, effective and patient-centred.

Whilst we as staff have a responsibility to continually reflect on our own practice, this must be fully supported, actively encouraged and consistently underpinned by honest reflection at a strategic level on the current ‘state-of-affairs’ and how this can be promoted and enhanced within the existing inflexibility of financial austerity.

Therefore, returning to our news headlines, what does the future hold for the NHS locally and nationally? Locally, despite considerable challenges, there are exciting times ahead as we look to fully embed health and social care integration and also move our main hospital services into our new build. Nationally, the picture is less clear with ever-increasing financial pressures being placed on continually growing workloads in a society with greater demands in terms of health due to conditions such as obesity, diabetes, heart and respiratory diseases. This is compounded by an ageing population sometimes presenting with chronic conditions which one simply did not survive from a decade or two ago.

hould we as NHS employees, the general public, healthcare service providers and users be concerned about the growing tide of negative headlines? Perhaps. Maybe these give an insight into the ‘health of our NHS’ – gosh, that’s a worrying thought. Or maybe, we now live in an environment feeding off news negativity and scandal in which we have all become de-sensitised to minor challenges therefore pushing media providers to ‘raise-the-bar’ in their reactionary reporting of our beloved NHS which would have, until relatively recently, been ‘off-limits’ to the eager reporter looking for a scoop however vague, misleading or sensational.

Lets return to our honesty theme. Within this blog, I have suggested that some honesty is required in our NHS and this should also extend to the reporting of challenges and issues to a certain extent. The antonym to sensationalism, where bad, critical or damming NHS news is forbidden with offenders punished by a stint taking minutes for certain western hemisphere parliamentary press conferences, is also not good for contemporary healthcare since this stifles and prevents honest reflection from which, lessons can be learned and development thrives.

There is every likelihood that the headlines wont go away and they may even increase in frequency or adversity. Perhaps though, if we all contribute in our own way, positive, honest and transparent analysis at individual, peer, organisational and national level will drive, develop and sustain an NHS we are all proud of and which we want to protect, however difficult or complex the discussions and decisions.

Barbara Tamburrini is an Advanced Nurse Practitioner at NHS Dumfries and Galloway

 

 

Improving Patient Flow by Chris Isles

Dave Pedley gave an excellent talk two Wednesdays ago on Tackling Crowding in Emergency Departments, triggered no doubt by the number of times recently we have been running at 100% bed occupancy with patients sitting in chairs in the Emergency Department because there were no free cubicles.

The nightmare scenario for us all as the clock ticks inexorably towards December 2017 is that the same thing happens when our fabulous new hospital opens and the TV cameras, newspapers and journalists begin to salivate at the prospect that something goes wrong (there will be no story to report if the transition to the new hospital goes smoothly and there are no corridor patients).

The chances that something could go wrong are actually quite high and the problem is almost entirely medical by which I mean the large number of frail older people living precariously in the community who fall, become immobile, incontinent or delirious and require at least some form of assessment but often admission to hospital.

The omens are not good.  Dumfries and Galloway has the second highest proportion of people in Scotland who are aged 75+ and living alone.  Our Health Intelligence Unit have shown that despite numerous initiatives and new ways of doing things the Medical Unit would be sailing perilously close to 100% bed occupancy if we moved into the new hospital today. (See me previous blog on the new hospital here)

During his talk Dr Pedley showed a powerful 5 minute video by Musgrove Park Hospital in Somerset entitled Tackling Exit Block ie their hospital’s inability to move patients through ED because of numerous interrelated system failures.  (https://youtube/WX1YwKIkWzA).  Musgrove Park ‘s Top Ten Reasons Why People Cant Leave Hospital were as follows:

  1. Discharge delayed so patient can have lunch
  2. Carer/relative can’t pick them up till after work
  3. Nurses too busy looking after other patients to arrange discharge
  4. Waiting for transport or refusing to leave without free transport
  5. Waiting for pharmacy
  6. Waiting for ward round
  7. Waiting for blood or scan results
  8. Waiting for discharge letters
  9. Packages of care planned for late afternoon/early evening
  10. Patient doesn’t want to go to the assigned bed in community hospital

During discussion a number of solutions to our own recurrent difficulties with patient flow were proposed.  These included tackling all of the above in addition to attempting to educate the public about when and when not to attend ED.  My own view is that this might be as fruitless as King Canute sitting in his throne on the beach and attempting to stop the incoming tide on the grounds that any patient who comes up to ED and is prepared to wait up to 4 hours and possibly more to see a doctor or a nurse must feel they have a very good reason to be there (one often quoted reason being that they could not get an appointment to see their GP).

There were some illuminating moments.  We asked Patsy Pattie whether Dynamic Daily Discharge was still as effective as it had been when it was first rolled out.  She replied that some wards needed support on embedding the process.  Dr Pedley praised staff for their firefighting skills on those occasions when patients were unable to access cubicles in ED which prompted Philip Jones, our chairman, to say that a corporate rather than firefighting response was needed.  Many heads nodded in agreement.

A corporate response might mean fixing lots of little things in order to make patients flow through the system more speedily.  Dynamic Daily Discharge could then become an established part of ward routine rather than an optional extra; the paperwork in the medical assessment area might need to be simplified to allow nurses to move patients into the body of the ward more quickly; a nurse on each ward might be designated to carry the ward phone rather than allow it to ring endlessly in the hope that someone else will pick it up; clinical teams would actively consider how patients might get home;  consider community detox for alcohol withdrawal; patients earmarked for discharge might move to the dayroom unless physically unable to do so; hospital taxis might take people home if relatives or patient transport cannot do so; patients could be issued with a prescription to take to their local pharmacy if new medications are required or go home with immediate discharge letter to follow if not.

To these solutions I would add fully funded Ambulatory Emergency Care and Comprehensive Geriatric Assessment services together with more and better social care and a commitment to fill the hospital with more staff on public holidays (of which there will be four within one month of the new hospital opening).

The Chief Executive of Musgrove Hospital finished her contribution to the Exit Block video by saying ‘we need every single member of staff to understand their responsibility in ensuring patients flow through our hospital so that we can discharge them home as quickly and as safely as possible’.  Who could disagree?

Professor Chris Isles is Sub-dean for Medical Education and is a Locum Acute Physician.