About dghealth

dghealth has been established to provide an opportunity for all employees of NHS DG to blog and share ideas and opinions and start conversations. There will be a weekly post. All blogs will be the personal work of the contributor and NOT official NHSDG policy. NHSDG have an Information Policy doc available on the Hippo website under useful I.T. forms

The Patchwork Quilt by Valerie Douglas

A doctor once told me that I had a portfolio career.  As my working life as a nurse in the NHS draws to a close it seems to me more like a patchwork quilt, assembled from many knitted squares.  Beginning in a psychiatric rehabilitation ward, I moved to acute admission in the old Crichton.  I dipped in and out of that ward undertaking secondments: to the Clinical Research Department, a Lecturer/Practitioner role, Care of the Elderly, Patient Safety and Improvement.  Then full circle, I moved back to rehabilitation nursing, this time interwoven with forensic threads.  Knit one, purl one.

Recently I’ve been on a partnership working secondment, with seats on the IJB and the RCN Board.  I have needed to insert some elasticated fabric into my knitting, as this has stretched me in directions unlike anything experienced before.  

With retirement imminent it is inevitable that I reflect on the whole quilt, the completed work, and remember the dropped stitches, the unravelling I’ve seen, the piecing together, the mending.  Some squares have faded with time but others remain vivid.

elegant ba blanket knitting patterns squares instant download pdf Patchwork Quilt Knitting Pattern

The Quiet Man.  This inpatient was polite, smart, of late middle age.  He wore his depression like a waistcoat watch, well-hidden in a little pocket.  You could just catch a glint of it if you really looked.  One Friday he went home for the day.  This wasn’t unusual.  He would typically return before 9 pm.  When he didn’t appear, staff phoned him.  No answer.  They phoned his family.  No, he didn’t have plans to come home that day, he had informed them explicitly.  Alarm bells rang and rightly so.  He never returned.  He had chosen a way out of his deep, silent despair.  Our thoughts of course went out to his lovely family for their loss.  But today my thoughts are also for us, the staff who nursed him, the doctors who treated him, the domestics who cleaned his room, the ladies at medical records who received those final ward documents.  I wonder if they still mourn him like I do over twenty years later.

Miss M.  Mute, traumatised, psychotic, she hardly ate or slept.  I was on a spell of night duty and would sit by her bed, talking to her, after giving her medicine.  She would listen intently, not responding.  ‘Looks perplexed’ were the words used most often to describe her in nursing notes.  After about a week she was out of bed when I arrived for night shift.  She glided around the ward, keeping close to the walls, vigilant.  One evening I took chocolate éclair sweets in.  I gave three to the nurse and three to the nursing assistant, saying to Miss M as she passed, ‘I’m leaving these three sweets on the table for you.’  She neither slowed nor acknowledged me.  A short while later the nursing assistant bounded into the office, ‘She’s taken those sweets.’  In mental health nursing it is often not diagnostic tests that expose signs of improvement, but observation and engagement.  Nurses can usually pinpoint turning points – medication has started to work, trust has been gained – and I have never forgotten the night of the sweets.  Each Christmas I’m reminded of Miss M when I hang the tinsel angel she made for me before her discharge.

Nursing has presented me with many patterns to follow, using different weights and colours of wool, some challenging designs.  Although all secondments have been worthwhile, I’ve always chosen to return to hands on nursing, the role I rate the highest, the role I value, the one I will miss the most.  Knit one, purl one.

 Val Douglas RMN, DipN, BSc (Hons), MSc Research (nursing)

Life changing events by Christiane Shrimpton

For those of us who have been working in healthcare for some time it can be difficult to remain aware of the patient perspective. For many patients what is part of everyday work for us is a significant change in their life. While I would not quite advocate the notion of medical students being forced to experience what life as a patient is like, this article really resonated with me. There still is a significant power difference between doctors and patients, something that Realistic Medicine is planning to reduce by promoting a shared decision making approach. And injuries or illnesses can lead to the traumatic disruption described, to the sudden loss of something you have taken for granted. A situation I am only too aware of at the moment.

I suddenly and rather unexpectedly found myself on the receiving end of healthcare following a cycling accident while on holiday in France. I seriously injured my arm and was stuck on the road until the ambulance arrived 30 minutes later. After several phone calls from the ambulance crew I was on a 60 minute journey to the nearest hospital with X-ray facilities. And unlike in the UK I was unable to get any pain killers until I got there as the ambulance did not have any paramedic. It rather brought it home how vulnerable you feel when you are in pain and don’t understand what people are trying to tell you – a situation our patients often find themselves in. While we don’t speak French it is very easy to use medical language because that is what we do with each other all the time. Are we always making sure patients understand? And how often do we really try to understand their perspectives and priorities, find out what the impact on them is? 

My experience of the doctors, nurses and other staff I have interacted with has mostly been good. They had sympathy for the loss I am so strongly experiencing and I have received a lot of excellent care and kindness. I have really appreciated what the NHS offers us here in the UK. And that has included the local hospital, my GP and the tertiary referral centre. Communication between all three has been good and the treatment I have and still do receive has made me feel very well cared for. There have also been aspects I have been less happy with. Overhearing that “bed 10” needed medication felt very impersonal and reminded me of Kate Granger’s # hello my name is campaign for more compassionate care. And there have been occasions when the information I was given by different members of the team seemed to be contradictory. That leads to an element of confusion and uncertainty.

All this has also led me to reflect on my role as an ophthalmologist. Have I been as understanding as I could have been when I had to tell people they will not get their sight back, they have to stop driving? I have always tried to understand the impact on them but I am not sure someone else can ever really understand what it is like. And I know that no matter how hard we try sometimes the message does not come across as we would wish. 

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This was just one of the two very significant changes in my life last year and they could not have been more different. The other one was entirely planned, a career move I had been working towards for a while. After more than 18 years in my previous mainly clinical job as an ophthalmologist I moved to Dumfries to take up the post of Associate Medical Director in the Acute and Diagnostics team. And I could not have been made to feel more welcome. It is fantastic to work with so many people passionate about making a difference to patients. As the news headlines remind us regularly, the NHS is under increasing pressure. So it is really good to see teams come up with innovative ways to overcome challenges. And it is also very important to keep supporting each other in difficult circumstances. Not everyone finds it easy to consider or adjust to different ways of working. I really enjoy getting out and about, meeting patients and staff, listening to their stories and connecting with teams. 

What my experience “on the other side” has also made me very aware of is how easy it is to come across differently to how we intend. And this is much more likely to happen while we feel under pressure ourselves, a common occurrence in the NHS today. We are all aiming to provide the best care we can for our patients. Let us remind ourselves to treat each other with compassion, too, and make the most of working together as multidisciplinary teams. I look forward to joining all the different areas to review our services and consider what improvements we can make. In all of this good communication and an understanding of each other’s perspectives is so important. Change is ever present and in the increasingly fast pace of life and healthcare delivery today all of us need to work closely together to support each other and achieve the best outcomes for our patients.

We will all experience life changing events at times. Some of them will be welcome, exciting and motivating. Others will be difficult and challenge us. Those of us working in healthcare are in the privileged position to be able to make a positive difference to people who are struggling. And we can all look out for each other and help those of us who like me will have to adjust to a different way of life with unexpected restrictions. 

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Christiane Shrimpton is a Consultant Ophthalmologist and Associate Medical Director for the Acute and Diagnostics Directorate at NHS Dumfries and Galloway

Love activity but hate exercise? by Erin Archibald

“Drop down and give me 20”…

What do you think about when you hear exercise and strengthening: sweatiness, gyms, Lycra, pain. As a busy mum to 3 children, exercise is something I don’t have much time to do but am I active? Absolutely!!

erin1I am a specialist Physiotherapist within the reablement service STARS ( short term assessment reablement team)- and my main role is to promote exercise and well being in the community- my target audience- not lycra gym bunnies, but over 65 year olds who normally have a long term condition who are recovering from a spell in hospital, and likely do not own trainers or know what a squat entails.  Who am I to advise to join a swimming group, attend low impact exercise classes or complete a rehab programme when I do not complete myself? Instead I walk to the park, climb up woods, I cycle with my children, I chase after them endlessly… so we need to think different about activity.

The benefits of rehabilitation, recovery and reablement support are well evidenced in Health and Social Care interventions.  The support improves a person’s ability to function independently, encourages exercise choices and to take control of their daily activities.

I work closely with 3rd sector and community teams, to encourage and promote active participation socially- tailoring every service users needs with their capabilities and skill sets and I see the patient as an individual not a condition.

  • what are their hobbies ?
  •  what do they enjoy the most in life?
  •  what is meaningful to them?
  •  what matters to them which they are currently not able to do or accommodate?

erin2We support service users to identify their goals through good conversations. We also support them to develop, retain and regain their skills by understanding what matters to them- this may not often happen initially but over the course of the reablement process from our support workers, we build relationships and find getting to know them and their families/carers imperative for helping them identify their goals.

We look at well being plans which can be something as simple as getting to the shop to purchase a daily paper, getting back to social activities, or being able to transfer into a bed or car again so they can visit someone important to them. We promote the benefits to exercise in line with recent evidence via Scottish government 2017.  Many include:

  • Reducing falls
  • Improving strength and balance-
  • Improve wellbeing
  • Reduce anxiety, improve sleep
  • Social Interactions/ reduces isolation
  • Day to Day activities become easier

As a registered practitioner, we document their wellbeing plans and agree this with the service user, enabling our health care support workers to deliver the daily practice of the chosen activity, whether this is a walk to the shop, a spot of gardening, making soup or practising stairs/ steps. This allows us to see progression and plan goals,

As a physiotherapist, I have blended alongside the occupational therapists in our team in the last five years to learn the importance of occupation (activity) led tasks and changing mindsets to linking social interests to exercise. In the time it takes someone to boil the kettle, they can do basic exercises such as the Balance challenge or super 6 exercise programme.  Reactivating “activity” to improve health and well being, Independence and quality of life is based on continuing research carried out at Newcastle University Institute for ageing with Professor Gore (2017). For example being able to reach your feet to cut your toenails, walk 400 years or maintain heavy housework. (http://www.knowedlge.scot.nhs.uk/ahpcommunity/lifecurve-survey-2017.aspx)

So, lets get more active and promote activity, lets think differently about exercise , and think about What matters to you for healthy ageing?

Erin Archibald is a Specialist Physiotherapist, STARS- Short term Assessment and Reablement service 28th January 2019.

The Key is in the Room by Eddie Docherty

edLast year, Scotland’s ­population was estimated to be 5,424,800 – a record high and an increase of 6 per cent on 2017. The largest increase of 31 per cent was in the 75 and over age group. It is, of course, good news that we are all living longer. However that increase in older age groups is hugely significant for our health and social care system.

The likelihood of being admitted to hospital is, as expected, highly ­correlated with the age of the ­population. Around one person in three of the Scottish population aged over 75 was admitted at least once to hospital in 2016/17. By way of contrast, just under one in 11 people aged 25-44 were admitted. Dumfries and Galloway had some of the dynamics no doubt many boards and hospitals have: staff who were doing their utmost, in sometimes very difficult conditions, endeavouring to give the best care they ­possibly could.

At the same time as we have an increasing demand in our hospitals, we have other pressures to manage which can impact on care, for ­example ongoing difficulties in recruiting to a range of posts, and a perennially challenging financial context. So when Healthcare Improvement Scotland’s inspections on the care of older people in two of our hospitals highlighted a number of concerns and challenges, it was a very difficult message for staff to manage – even though we knew the findings were accurate. There is a natural emotional response that comes from staff who are working hard, doing their best and feeling like the criticism is unfair. After all, no one was ­coming to work to do a bad job. I have no doubt many who have received challenging inspection reports have felt the same. Yet, after that initial, understandable, emotional response, what has happened since those inspection reports were published has been hugely positive. That subsequent reaction has been down to the staff themselves, who chose to respond to the challenges in a way that that has empowered them and benefited patients.

The key to the positive response was in managers and staff using the feedback, taking stock and ‘owning’ the areas that needed improvement. There was no one silver bullet to the improvements taking place but a combination of factors which included an understanding that answers to improvements lay ‘in the room’; teams delivering care were empowered to make the changes they needed to make; we had a strong group of individuals who wanted to make the changes; and the key thing to change was creating a culture of person-centred care and it was staff who could shape this. So, having weathered the ­challenge, staff developed an action plan and used improvement methodology from Healthcare Improvement Scotland’s ihub to support the improvements, look at best practice from ­elsewhere to understand how to make change happen. It has taken at least 6-8 months for changes to feel tangible and there have also been some personnel changes which have added impetus to the cultural change. However, it is important to say that it is the teams themselves that have taken responsibility for change.

The latest inspection reports in to the two hospitals concerned are in stark contrast to the initial reports – inspectors positively commenting on team work, ethos and person-centred care.

It has been a major turning point for staff. It feels like there has been a clear psychological change – and a change to a more positive ­perception of inspections themselves. Staff will now welcome the inspectors and the inspection process, knowing that this is an opportunity to get better. They know that they can make the most of the improvement support that is available from Healthcare Improvement Scotland and feel they are able to embrace both aspects. One of the added benefits of the changes was that, across the service in Dumfries and Galloway there has been a less fragmented feeling, and more of a feeling of a team ethos. In addition, it also feels like there has been change in the working environment to one that is a more open, learning environment. However, there remains room for improvement and I’m not saying we have solved all issues.

But it feel like we are more confident and in a better place to use challenges from inspections, and the improvement support available, to improve care in a way that might not have happened before. For that, the staff in Dumfries and Galloway hospitals can take a huge amount of credit.

Eddie Docherty is Director of Nursing at NHS Dumfries and Galloway.

This article was originally published in the Scotsman online on the 15th January 2019 and can be found here.

 

 

Two tins of soup by Libby Johnston

libby 1When asked to submit something for the blog quite some time ago, the suggestion was that the subject be something that readers would find moving in some way. Recent press has been highlighting the degree of loneliness some are experiencing and how it can effect wellbeing physically, mentally and isn’t always visible to others.

In the run up to Christmas festivities I went to one of the so-called Pound shops. It leans towards my frugal nature and there is nothing like a bargain. However many use such shops to survive with a limited budget.

As I wandered down the first aisle a rather frail but spritely elderly woman moved to allow me to pass and I thanked her and we exchanged pleasantries. As I made my way through the aisles and shelves she seemed on the same route and I couldn’t help but overhear her saying ‘Merry Christmas’ to virtually every person she encountered. I made my way to the checkout and there she was again in front of me in the line. As I looked at her clothes, I could see that she had many layers of threadbare jumpers and no coat on what was a cold day.

She seemed to know the person at the checkout and was asking if they were ready for the holidays and he asked her the same to which she answered yes this was her last shopping trip. On the conveyor belt were 2 tins of soup. He commented, ‘No turkey’? She shook her head, saying nothing and placed the tins of soup in her shopping bag, continuing to wish everyone around her a Merry Christmas and the same to us as she trudged out of the shop, bag in hand. My heart was full as she had shared the joy of the season with everyone she encountered in the shop and yet there was a loneliness to her life.

As a nurse and midwife (retired), it’s always been in my nature to reach out and help others in need. I desperately wanted to ask this dear lady if she was having a Christmas meal with anyone and if not invite her to share ours. I feared she might only be facing a tin of soup. However, she had disappeared from sight and I will never know.

It left me feeling a touch of sadness for her. There is much awareness about people being lonely and particularly at this time of year. Many organisations, charities are endeavouring to help those who may be lonely. There will always be those who won’t want help and soldier on like this woman who found some company, even joy in sharing festive greetings in a shop. A lesson perhaps for the less lonely to be bolder in reaching out to others not only at Christmas but in everyday life.

The government is investing in ‘loneliness’ as it is felt it has been shown to impact health and wellbeing. This is highlighted in this article in The Guardian:“UK to tackle loneliness crisis with £11.5m cash injection”

The money will help establish projects that will bring people together and in so doing reduce elements of loneliness, improving health and wellbeing.

 

“Loneliness and the feeling of being unwanted

is the most terrible poverty.”

Mother Teresa

Sending love at Christmas…. by Mairi Small

Christmas is inextricably linked with love…..

Dean Martin sings about having his “love to keep him warm” – if you would like to spend a couple of minutes warming the cockles of your heart click here

Smokey Robinson and his Miracles feel that if their baby loves them too, it would be Christmas every day and annually, in early December, we’re reminded that all Mariah wants for Christmas is youuuuuuu. (The remainder of the song choices in the collage are for you to ponder whilst digesting your turkey on Tuesday)

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In Cardiac Rehab we love to sing and have a soundtrack to each of our weekly exercise sessions which are held in venues throughout D&G. Sometimes, the music choices are a little bit Homes under the Hammer-esque…. “Dont Go Breaking My Heart”, “Under Pressure”…..  And of course who could forget the dulcet tones of Billy Rae Cyrus belting out “Achy Breaky Heart” in years gone by (for those under 30 reading this, Billy is Miley Cyrus dad). But C/R isn’t “just an exercise class” as anyone who has ever had experience of our service will testify – so what do we actually do?!

Well, since “last Christmas”, the C/R service in D&G has supported over 500 individuals following a cardiac event. The British Association for Cardiovascular Prevention and Rehabilitation (BACPR) define priority groups for inclusion as post MI, coronary revascularisation (stents or bypass) and heart failure.  Locally, we also include those with a diagnosis of angina, post valve repair/replacement, post implantation of cardiac defibrillators and resynchronisation devices, post heart transplantation and ventricular assist devices and adult congenital heart disease.

The service was set up in D&G in 1990, with an extensive, worldwide evidence base being consolidated since – C/R reduces cardiac mortality by 26% and unplanned hospital admissions by 18%. Currently based in Cluden Cardiac Unit in Crichton Hall, we are set to move into Mountainhall in early 2019. We see inpatients in both DGRI and GCH and run out patient clinics regionwide. We are a small team of nurses and physios who work closely with a wide range of health care professionals, services and organisations.

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Although C/R nationally is undergoing a programme of modernisation in line with Scottish Government priorities, it maintains its traditional “menu based approach” with patients choosing the components that matter to them.  So, whats on the C/R menu this Christmas, and beyond?!

To start

Identification, referral and recruitment of eligible patient populations – referrals tend to be picked up during in patient stay or from tertiary centres but we also accept referrals from other HCPs.  Referrals can be sent electronically to – dumf-uhb.CardiacCommunication@nhs.net

Early initial assessment of individual patient needs – including medical history (a significant proportion of patients will have one or more co-morbidites), relevant investigations, social determinants of health, lifestyle risk factors, psychosocial health and medical risk factor management.  This may take place in hospital, the patients home or out patient clinic and may be completed over more than one contact.

Agreed personalised goals – to be reviewed throughout the episode of care.  This really is the “what matters to you” bit of the programme.  Goals may range from “aim for 3000 steps a day” to “get back to work” to “get back to singing with the choir”.

To follow

Health behaviour change and education – this may include addressing cardiac (or other) misconceptions and illness perceptions that may lead to increased disability and distress, support of the patient’s significant other/s, goal setting and pacing skills, and facilitation of self management skills. Discussions may include – pathophysiology and symptoms, management of risk factors such as BP and lipids, occupational/vocational and driving advice, resumption of sexual relations and dealing with sexual dysfunction.

Lifestyle risk factor management – a trio of physical activity and exercise, healthy eating and body composition and tobacco cessation.

Running heart

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Individualised advice on ADLs and a tailored activity and exercise plan aims to increase physical fitness as well as reduce sedentary behaviour. Home based exercise plans are offered for those unable to uptake on traditional group exercise sessions and patients also get the opportunity to exercise within local authority leisure facilities. We are currently exploring the use of technology by way of short term loan of Fitbits to ascertain baseline activity levels and encourage an increase in an individuals “active minutes”.

Following baseline assessment of dietary habits, weight, BMI and waist circumference, a focus is on the adoption of a cardioprotective diet which encompasses healthier dietary choices, correcting misconceptions about diet and health, and body weight maintenance (or reduction if appropriate).

Patients who are smokers at the time of assessment are referred to the Quit Your Way service in addition to the C/R team providing education and support in the preparation and attempt at smoking cessation.

Psychosocial health – all patients are screened for psychological distress using validated tools and individual assessment allows for discussion regarding illness perceptions and self-efficacy for health behaviour change, and to determine levels of social support. Patients are encouraged to practice relaxation strategies or mindfulness exercises regularly and are offered taster sessions as part of the programme.

Medical risk management – optimisation of cardioprotective therapies is guided by regular measurement of BP, heart rate and rhythm, glucose and lipids. This provides an opportunity to discuss dosage and adherence with the patient and address their beliefs around their medication regime. It is hoped that some of the team can become independent prescribers to streamline the process of up titration of the secondary prevention medication in the longer term.

BHF Heartstart training – all patients and their family/friends are invited to attend this two-hour session to learn how to recognise an MI/cardiac arrest and deal with a life threatening emergency – perform CPR, access and use an AED, deal with choking and serious bleeding. This year 239 individuals across D&G have attended a Heartstart session run by the C/R team.

To finish

Final assessment of individual patient needs – to determine the effectiveness of our interventions, we are currently reorganising our service to create time for a more comprehensive final assessment to take place. To date this has been done quite informally but we feel it would enhance the patient experience to revisit baseline measures and formalise the ongoing management plan collaboratively. Patients are given details of local community based services and opportunities to support their self management moving forward.

Audit and evaluation – the uptake of C/R throughout the UK is variable but it is pleasing that locally we are supporting many more than the national average of around 50% of patients following a cardiac diagnosis. We have a robust audit process in place within D&G and are currently exploring how this may feed into a UK wide dataset to further strengthen the evidence base for C/R interventions.

Coffee and mints

In keeping with C/R tradition, on noteworthy occasions such as retirements and birthdays an after dinner ode to the recipient is dished out along with the coffee. With this in mind….

An ode to NHS D&G staff at Christmas

As Andy Williams famously sang, “it’s the most wonderful time of the year”

Perhaps you’ve spent the last few weeks thinking to where did 2018 disappear?

Now is the time for some fun, rest and reflection, hopefully in equal measure

To celebrate Christmas your own way and with love, kindness and pleasure

Although joyous for many, the festive season can be a sad and difficult time its true

Loneliness, loss, illness, expectation and pressure, maybe feeling more than just a bit blue

Christmas, like a heart attack, doesn’t always look like it does on the big screen

A time of remembrance and contemplation, hopes of what the year may have been

The pace of change in modern healthcare often goes at a rate of knots

Feels like there’s hardly time to do the job, let alone gather your thoughts

We all know too well of the “winter pressures” which don’t seem to relent much year long

Working difficult and unsocial hours, away from our loved ones, where we belong

It’s sometimes hard to remember that we all do a great job and are part of a fab wider team

It’s easy to criticise and get despondent when it doesn’t feel like you’re living the dream

But our local health services are truly amazing and star several thousand of a diverse cast

Staff who are caring, loyal, highly skilled and adaptable, genuine healthcare enthusiasts

So, take some time to enjoy your Christmas soundtrack and whatever is on your menu

The little things in life are often the best, regardless of the venue

Take some time to do “what matters to you” and enjoy some festive cheer

Wishing you and those special to you, health, happiness and peace throughout the New Year.

The cockles of the heart are its ventricles, named by some in Latin as “cochleae cordis”, from “cochlea” (snail), alluding to their shape. The saying means to warm and gratify one’s deepest feelings.

Mairi Small is a Senior Physiotherapist at Cardiac Rehabilitation for NHS Dumfries and Galloway

‘Docere’ by Sonia Cherian

The word ‘Doctor’ is the agentive noun of the Latin verb Docere which means ‘to teach’. The title ‘Doctor’ refers to a person who is recognised to have acquired sufficient knowledge in a subject to be a teacher of that subject. The role of the doctor as a teacher helps educate patients about their condition. A well-informed patient is crucial to the success of any treatment plan. In an era of increasing demands on the healthcare system coupled with  changing patient expectations, the doctor’s role as a teacher has a unique significance.

The supreme court ruling in the Montgomery case (Montgomery v Lanarkshire Health Board, 2015) was a watershed moment from a medicolegal perspective. Mrs Montgomery, a small built diabetic patient had complications during a vaginal delivery which resulted in her son being born with severe disabilities. The case hinged on whether the health board had provided her with all the information which could have helped her make a decision between a normal delivery or a caesarean section. Her obstetrician felt that the risks of shoulder dystocia during normal labour was not significant enough to discuss with her thinking that this information may have resulted in the patient choosing a caesarean section which had its own risks. The supreme court felt that had the risks been explained fully to the patient, she would have opted for a caesarean section and the baby would have been born unharmed. This ruling established that a patient should be told whatever they want to know, not what the doctor thinks they should be told. Mrs Montgomery was awarded a compensation of £5.25 million and the ruling fundamentally changed the law on decision making with the transition from ‘medical paternalism’ to ‘patient autonomy’. The ruling makes it clear that any intervention must be based on a shared decision-making process ensuring the patient is aware of all options and supported in making an informed choice by their healthcare professional.

The General Medical Council (GMC) document on Good medical practice advises to work in partnership with patients:

  • You must listen to patients, take account of their views, and respond honestly to their questions.
  • You must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs.
  • You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.

(https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/domain-3—communication-partnership-and-teamwork#paragraph-46)

The Realistic Medicine agenda led by the Chief Medical Officer (CMO) of Scotland makes shared decision making and a personalised approach to care its key themes. (https://www.gov.scot/publications/practising-realistic-medicine/)

‘The King’s Fund’ research recommends that patients should be given a chance to take an active role in decisions about their care and treatment by providing the right opportunities, information and support. Services should reflect the needs of patients by meaningfully involving patients and carers in service commissioning, planning, design and improvement. (https://www.kingsfund.org.uk/publications/shared-responsibility-health)

An informed patient can positively contribute to decision making regarding a personalised approach to his or her treatment. This would also mean that patients are more open to share the responsibility of these decisions and be prepared to live with the consequences of their choices thus reducing the risk of complaints and litigation. Patient decisions are not only influenced by medical considerations but also by non-clinical issues which are of relevance to that individual patient. Values, beliefs and life experiences that have a personal significance can influence choices. Our role as clinicians is to support the patient in the decision-making process by providing expert medical advice through a dialogue. Unlike emergency situations where decisions have to be made quickly to save the life or limb of a patient, the vast majority of treatment decisions are taken in primary care or in an elective setting in secondary care. Many conditions have a variety of treatment options, each with its own benefits and risks. In some situations, having ‘no treatment’ is also a reasonable option.

Many patients are well-researched about their condition having read various articles on ‘Google search’. However, for a non-medical lay person to comprehend the vast, often confusing and sometimes contradictory online information can be challenging. This may leave patients with incomplete and out of context information. Hence the information that the patient could assimilate online is quite different from the knowledge that he or she needs to make personalised treatment choices. The clinician has the unique role as a teacher to help transform the information the patient has into knowledge whereby safe personal choices on treatment could be made.

Discussion regarding the various methods of Patient education is a topic on its own and is beyond the scope of this blog. Though innovative ways to deliver succinct information using digital media seems to be the way forward, these would never replace the warmth and compassion of a caring competent clinician who would help patients make the right balanced choices. This would only be possible with the provision of time and resources to improve meaningful information sharing during consultations.

The CMO’s annual report (2016-17) acknowledges that the main barrier to healthcare professionals having more in-depth discussions with patients is the issue of time. “Simply offering the standard treatment or investigation may be quicker, but not necessarily what is in the patients’ individual best interests. It is essential that in order to provide high quality, personalised care clinicians are in a position to make the time to have these important discussions. If we are able to move towards engaging in these conversations as a part of routine practice, it is likely this will in some circumstances save time where patients decide against investigations or treatments that they do not feel are right for them.”

The second Citizens’ Panel Survey (August 2017) revealed that the behaviour/style of the doctor and how busy they are (or are perceived to be) had an impact on patients’ inclination to ask questions. The current legal and regulatory requirements make it the responsibility of the clinician to provide adequate time to the patient so that they are well informed prior to making a decision.  However, the Scottish Public Service Ombudsman (SPSO) has commented in the CMO’s Annual report (2016-17) that this responsibility is not that of the clinician alone. This process would require policy changes within the organisation and a change in culture that encourages and fosters patient centric multi-disciplinary team working.

The GMC guidance, the Supreme court ruling, the concepts of Shared decision-making, Patient centric care and Realistic medicine all point to the pivotal role of patient education  thus highlighting the importance of what it truly means to be a doctor : ‘A Teacher !’

Therefore, let us all remember to teach before we treat !’ and support each other in patient education with the ultimate aim of delivering holistic patient care.

 

Dr. Sonia Cherian is a GP at NHS Dumfries and Galloway as well as a GP Appraiser and CPD Adviser at NHS Education for Scotland

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