Time to prepare for our new hospital by Chris Isles

This has been a busy month for the NHS. England has narrowly avoided a 24 hour strike by junior doctors, the difficulties experienced by the Queen Elizabeth Hospital in Glasgow have been laid bare on national television for all to see and Question Time debated passionately whether the NHS would fail this winter. Locally, Katy Lewis, our finance director, told a packed audience at our Wednesday Clinical Meeting of the financial difficulties faced by our Health Board while Ewan Bell, Associate Medical Director, wrote a blog about Prioritising Health Care and the chairman of our Medical Staff Committee drew our attention to Audit Scotland’s report on the state of the NHS in Scotland 2015.

Did I hear/listen to/read them all correctly? Can it really be true that the fifth largest economy in the world cannot afford to provide safe, high quality, emergency health care that is free at the point of delivery? 

Let’s start locally. Unless I am very much mistaken we have two major challenges in the run up to our new hospital opening in December 2017. We desperately need to avoid the scenes in Glasgow of ambulances queuing outside A&E and trolleys stacking inside A&E and equally we need to ensure that there is sufficient social care for our frail elderly patients when they go home from hospital. The challenge is likely to be greater for Dumfries and Galloway which has the second highest proportion of people in Scotland who are aged 75+ and living alone.

Chris 1

Katy Lewis spoke of the need for transformative change (aka doing things differently). Who could possibly disagree? If we carry on as we are doing now then the tidal wave of unscheduled medical admissions will cause our new hospital to silt up on the day it opens.  This is the conclusion I have drawn after analysing data provided by our own Health Intelligence Unit (the figure below shows the medical unit is sailing perilously close to 100% bed occupancy) and it is the nightmare scenario we must all be dreading. It should surely be concentrating everyone’s minds. If we get this wrong it won’t just be the local newspaper that will have a field day.

Chris 3As it happens we have been working on ways of doing things differently and have identified two possible solutions: Ambulatory Emergency Care (which does what it says on the tin) and Comprehensive Geriatric Assessment (see below for definition). We must also ensure that we staff the new Combined Assessment Unit adequately. Both AEC and CGA will require investment if they are to be part of the organisation’s response to an impending beds crisis.     Other hospitals in Scotland have already embraced AEC and CGA and there is published evidence to support the view that these examples of transformative change will reduce bed occupancy. Has anyone come up with a better idea?

Equally if we are to keep that new hospital flowing we must invest in patient transport and community support services, particularly social care teams, providers of equipment, community nurses and carers.   The unintended consequence of preventive medicine is that we have more frail elderly people to look after than ever before. Their numbers appear to be increasing as the number of carers available to look after them decreases.  It can surely come as no surprise to learn that carers are in short supply when some are only paid £6.70 per hour (even less than this when we don’t pay mileage or travel time between visits). Compare this to a consultant physician on £36-44 per hour and the eye watering sums of up to £120 per hour we spend on some of our locums. The enormous difference between carer and locum salaries simply has to be addressed.  

Audit Scotland say that ‘significant pressures on the NHS are affecting its ability to make progress with long-term plans to change how services are delivered.’ The title of Katy Lewis’ presentation was ‘Austerity or Bust’.  Ewan Bell wants us to acknowledge that ‘we can’t continue to provide the current range of interventions and services, if we want a sustainable NHS for the future.’ I personally believe that the 5th largest economy in the world could afford to provide high quality emergency care as well as batteries for hearing aids and palliative chemotherapy for the frail elderly (if that is what they really want), but if I am wrong then surely the batteries and the chemo must go.

Chris Isles is a ‘semi-retired’ Consultant Physician

Comprehensive Geriatric Assessment: ‘a multidimensional and usually interdisciplinary diagnostic process designed to determine a frail older person’s medical conditions, mental health, functional capacity and social circumstances. The purpose is to plan and carry out a holistic plan for treatment, rehabilitation support and long term follow up.’

There are only four types of people in the world….. by Lindsay Sim & Sharron McGonigle

‘There are only four types of people in the world…….those who have been Carers, those who are currently Carers, those who will be Carers and those who will need Carers.’

Carers 1In this current climate of integration, it would bode us well to remember the above statement. Dumfries & Galloway Carers Centre has historically always promoted and encouraged partnership working but now it’s something that we have all been directed to achieve together under the Scottish Government Health & Social Care Integration Policy.

Are you letting your patients and their Carers know about the services that you yourself may need someday or are you assuming that someone else has done it? Don’t you want to be the person who lets a Carer know about the services they could access so that it can make a huge difference to their life? In order to give the Carer the smoothest journey throughout their caring role (which is likely to be us all at some point in our lives) we need to be aware of the issues Carers face and try and work together to make their journey have as smooth a road as possible.

Carers 2If a referral is made to the Hospital Carers Support Project at the very beginning of a Carers journey, for example a stroke diagnosis, a cancer diagnosis, newborn baby with a disability, long term condition, brain haemorrhage (and the list goes on) it has been proven that the Carer feels supported, listened to and most importantly identified as a Carer who needs supported throughout their journey. Early intervention can mean a lesser impact of a caring role upon someone’s life with the correct support.

Carers have vital information to offer health professionals about the person they care for; they know the person inside out so this is more than beneficial to the professional involved as the Carer has firsthand knowledge on how the person they care for functions on a daily basis. Carers need advice on how to cope in the future, need help to access different services or simply want to know about progress and the outlook for the future. The advantage of sharing information with Carers is crucial in acknowledging the important role they carry out.

Carers have a large part to play in helping their cared for recover and ensuring their continued health. To do this, Carers need access to the right level of information. The Hospital Carers Support Project’s Coordinators frequently speak with Carers reporting that they feel cut off from the care of an individual to whom they have provided considerable support. The Carer is continuing to duplicate the care you administered once they get home after discharge. The Carer continuing what you have been doing in the hospital is vital in preventing re-admission. Many Carers also discover our Project for themselves by chance and tell us that no-one directed them to our service for support.

Why is it, when we have so much good policy and practice to help us support Carers through their journey, that some Carers still feel unrecognised and state that they feel they are not treated as partners? Identifying and referring a Carer to the Hospital Carers Support Project early on in their caring role means the Carer can access the following support….

  • Instant access to support whilst their cared for person is still in hospital
  • Information and advice
  • A listening ear
  • Assistance to have a voice in their cared for person’s discharge from hospital
  • Advocacy
  • Benefits advice
  • Training and education
  • Access to address their own health and wellbeing
  • Accessing a Carers Support Plan which looks at their caring role now and plans for the future
  • Funding and grants to access a break from their caring role
  • Activities and groups where they can meet up with other Carers
  • Access to counselling

If Carers and the people they support are informed, involved and supported throughout their caring journey, the likelihood of good outcomes rises, risk of re-admission falls and the financial and emotional costs this incurs can be avoided. Thinking about all the other services out there that are available to Carers is vital in giving the Carer the support they need. Don’t wait until you are a Carer yourself before realising that it can be a difficult, isolating, heavily impacting and frustrating role before remembering all the people you could have pointed in the right direction.

 

Carers 3Did you know that the Hospital Carers Support Project, part of the wider Dumfries & Galloway Carers Centre has been based within Dumfries & Galloway Royal Infirmary for the last 14 years? We have supported over 1500 Carers with issues ranging from debt management, housing problems, applying for funding, arranging counselling; applying for benefits, accompanying a Carer to a hospice with their terminally ill child, liaising with ward staff, sorting out accommodation, listening when no-one else has, the list is endless. There is no problem that we won’t at least try and find out the answer to when trying to make the Carers journey more seamless but to achieve this we just need you to let us know who we can help……….

If we all work together – it will all come together.

Carers 4

 

Lindsay Sim & Sharron McGonigle

Hospital Carers Support Coordinators

Hospital Carers Support Project (part of the wider Dumfries & Galloway Carers Centre)

Support & Advice Centre

Dumfries & Galloway Royal Infirmary

Tel: 01387 241384 #33384

email: dgcarers@nhs.net

 

 

 

 

Resistance is futile by Euan MacLeod

Euan Borg 1

Assimilation or Integration?

For those of you familiar with Star Trek you will immediately recognize the Borg phrase Resistance is futile. The full version is “We are the Borg. Lower your shields and surrender your ships. We will add your biological and technological distinctiveness to our own. Your culture will adapt to service us. Resistance is futile.”[.

Is that how it feels for you as we undergo a period of change and is Integration a bit like the equation below?

 

The rule for integration isEuan Borg 2 providedEuan Borg 3

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Well what can the Borg add to this?

I decided to research this a bit more and see if the Borg approach to other species was just as simple as taking them over and those species who were assimilated losing identity and just becoming part of a big machine.

The Borg operates toward the fulfilment of one goal “achieving perfection”, they exhibit a rapid adaptability to any situation or threat, and they have an ability to continue functioning after what may seem a devastating or even fatal blow.

So what is the goal of Integration, I think most of us would agree that it is designed primarily to improve the delivery of high quality compassionate care by enabling all involved in delivering that care to function more collectively.

Resistance to the changes that integration brings may develop unless people think that they will make a powerful positive difference to patient care. We will also I think need to feel that changes will enable us to do our jobs better and maintain, strengthen and develop the key working relationships that high quality compassionate care is based on. To be able to operate compassionately is a key relational aspect to our character as human beings.

 Euan Borg 5

The strength of the Borg collective is a pervasive collective consciousness that enables all the drones to feel what the other drones are experiencing, in the collective each individual is given constant supervision and guidance, being part of the collective consciousness offers advantages to the individual drones. Does being part of something bigger benefit you in delivering compassionate care and what are those key relationships that help you achieve that goal?

 Euan Borg 6

The Borg are more interested in assimilating technology than people and they don’t assimilate any old species only those who might add to their overall goal of progress towards a more efficient way and achieving perfection. At times the outcomes and progress we are chasing seem more about productivity, efficiency and cost effectiveness, and perhaps less explicitly so about high quality compassionate care.

Pursuing high quality compassionate care should deliver productivity and efficiency so perhaps assimilating those aspects of how we all do our work into a collective approach that delivers high quality compassionate care will be helpful.

 Euan Borg 7

So assimilation or integration or is it a bit of both

Looking up definitions of these we find it most commonly is applied to questions of immigration, culture and identity

Questions about culture and identity are fundamental as we go through this process, how we react to that will to some extent define whether we experience assimilation or feel that we have become integrated into a bigger whole that displays parts of our unique culture and contribution in fulfilling our goal.

The Borg operates on a basis of collaboration and this is built on mutual altruism, mutual concern and mutual support which are focused on achieving their goal. Can we do the same?

Euan McLeod is a Senior Project Officer for the National Bed Planning Toolkit

Winter is coming (but that’s OK) by @JeffAce3

I might be tempting fate here, but I’m in an unusually bold mood and I’m just going to go for it… it’s time to declare winter 2014/15 officially over.

Despite living here through the last fifteen of them, I’m still a little in awe of Scottish winters with their frozen lochs and snowfalls into April. I grew up in South Wales (which, for those of you who haven’t been there, has a broadly Mediterranean type climate…) and the adjustment to more northerly weather takes a long time. Indeed, the Ospreys rugby team’s narrow miss of the league title this season is largely accredited to our failure to wear thick enough vests during the trips to Edinburgh and Glasgow.

Jeff Ace 3 (1)

A typical midwinter scene at Torbay, Swansea.

Sadly, it’s hard to mention ‘winter’ in an NHS context without immediately adding ‘pressure’. Locally, this was a record breaking year in terms of winter admissions to hospital and patient activity through primary and community services, a fact which is quite staggering when you think that the previous two winters have also broken records.

 Jeff Ace 3 (2)

 

We’ve experienced all the usual difficulties of Norovirus and Flu outbreaks amidst this record activity and it’s to the enormous credit of staff that we’ve maintained extremely high performance levels. For example, the 95% 4 hour wait target in A&E has proved impossible to achieve across much of the UK; our teams not only delivered it, but improved on previous years’ performance. This is much more than an impressive set of statistics; this was a major contribution to good patient experience and safety.

 Jeff Ace 3 (3)

 

There are lots of other examples of the huge efforts of staff in improving services throughout the pressures of winter. We’ll be reviewing a range of such information at our NHS Board public meeting in June, so I’d expect forthcoming media reporting to be even more heavily dominated than usual by praise for our teams and their achievements…

We should take pride in these achievements but I’d also like to reflect on how this level and quality of service can be built on as we begin the winter planning for 2015/16. The ‘winter pressure’ this year has fallen squarely on teams of staff dealing with unprecedented gaps in staffing due to well publicised recruitment problems. We have succeeded for our patients this winter frankly because many clinical and support teams have worked harder and longer than ever before. I can make this statement knowing it applies right across our system, from the primary care teams coping with GP vacancies, to the cottage hospital staff managing record levels of occupancy, through to our acute teams juggling rotas around consultant and other doctor vacancies. This is a great reflection on the ethos of our teams, but it can’t surely be the basis of our long term planning; it can’t be our ambition to ask individuals and teams simply to work harder year after year to deal with rising patient activity.

It’s certainly not my ambition and I instead want us to be seen as the outstanding place to work and to develop your career in Scotland. That has to mean relieving some of this pressure on individuals and teams to allow them to focus on continuing to improve our patient experience rather than simply ‘fire-fighting’ a relentlessly rising workload. In years gone by this would have been quite a simple process; a (often young, Welsh) manager would put together some demand and capacity analysis, demonstrate the imbalance and cost out the required extra capacity in a bid to the Health Board. The Board would then consider this in the context of other priorities and, more often than not, commit a proportion of its growth monies to fix the problem. Life’s now a lot more complicated. In the next few years this ‘growth’ funding barely keeps pace with health inflation and even where money is available, we’ve no longer a guarantee that we can recruit to traditional roles.

But whilst previous solutions may no longer be as effective, I think we can still allow in some cautious springtime optimism that a more sustainable future is achievable.

Health and Adult Social Care integration is one of the reasons to believe the future could look significantly different. First the injection of pragmatism; integration doesn’t magic up one more GP, social worker or care worker, doesn’t add a pound to our stretched budgets or endow our managers with (even) greater wisdom. It does, however, give us the first real opportunity to pool our resources and expertise in each of the region’s natural localities and try to create local models of health and care that are more effective at managing complex conditions in home or community settings. We now have a bank of evidence from the Putting You First change programme of the impact of small scale redesigns, integration allows us to take the best of these and implement them at a scale that could make a fundamental difference to flows of patients and to the quality of experience of those patients. This will be a difficult process of enormous change to many clinical practices and pathways, but it seems to me that it offers promise of genuine sustainability of service quality as an alternative to a future of perpetual winter pressures. Our integration scheme is the most ambitious in Scotland, has been approved by both Board and Council and we go live on 1 April 2016 after a period of ‘shadow’ running this year.

Similarly, the ‘Change Programme’ (part of the suite of work around the new acute build) gives us a once in a generation chance to examine every aspect of our organisation of acute workload. We know that come 2017/18 we’ll have the finest DGH facility in Europe, the contract’s signed and the diggers are on site. We need now to ensure that services in the hospital from acute receiving to theatres to outpatient reviews are reorganised in a way that gives staff the very best opportunity to deliver high quality care and act as the best advert for recruitment of top class staff. This isn’t quick fix work, but again offers us an opportunity for improvement that we’d be foolish to miss.

I don’t want to put a rose tinted perspective on what are the most challenging times in health services I’ve seen in my career. I also appreciate that engaging in such major redesign programmes is particularly difficult when faced with increased demands of the day (and night) job. But I do think these programmes are our best strategy, and that locally we have a unique opportunity to create a future that feels a bit more balanced, and winters that feel a little more fun.

Jeff Ace 3 (4)

Jeff Ace is Chief Executive Officer for NHS Dumfries and Galloway

 

“Public Service –What’s that all about” by @Mac_imar

 

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We have seen from recent blogs that we celebrate 66 years of the NHS (Happy Birthday NHS !!!!! by @shazmcgarva & @Emmcg2, 04 July 2014) and that it is a treasure we hold dear as can be seen from the high profile it received during the referendum and the current focus as we lead up to a general election.

What was the original idea behind the NHS and the creation of the welfare state and what is the notion of public service and what, or perhaps who are we here for?

When William Beveridge in 1942 produced the blueprint for the welfare state he had” five giants” that needed to be eradicated, these were ignorance, squalor, want, disease and idleness. This blueprint ultimately led to the creation of the welfare state and the National Health Service that was founded by Aneurin Bevan in 1948.

In tackling these the welfare state grew into something he didn’t predict, an over professionalization of services that relied on high tech equipment, professional knowledge and sophisticated processes, which ultimately created dependence and lack of resilience within the communities it served.

This I think reflected some of the pejorative language we use, terms like our patients, my patients framed a “we know best” approach, but we now see the development of a more personalised approach which identifies personal responsibility and some degree of accountability to be involved in our own healthcare and become partners in collaboration rather than passive participants

A more facilitative partnership approach to delivering health care commonly described as Co-production drives a process to involve people in this sharing and supports the development of community resilience i.e. people helping themselves. This starts to shape our role into “helping people decide not telling people what to do” and was eloquently described by Shaun Maher in his blog titled “Keeping the lights on” (@Shaun4Maher, 22 August 2014) by the difference between asking “What matters to you?” not “What is the matter with you?” This approach is also well established within the Health Improvement work taking place in D + G and by Elaine Lamont blog “Services…but not as we know them” 26 September 2014.

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So how do we know if we are managing to do this effectively and provide high quality health and social care to those whom we serve?

Most commonly in the NHS and Social care a lot of what we do is driven by the need to meet various targets and attain levels of quality by implementing a variety of improvement programmes

Measuring what we do and telling our story of how well we are doing sometimes doesn’t match up, how often you have heard people say “that score or report doesn’t reflect accurately what we do”

It can be easy to become demotivated, frustrated and feel that what you do doesn’t have a positive effect and that you are drowned in form filling, report writing and action planning. A recent (2010) study called “the Bermuda triangle” found that in one hospital there were 515 projects all linked to improvement work, another hospital started a balanced scorecard approach with 4 strategic categories that then developed into 252 performance measures

This created increased workload and meetings which focused people’s attention on compiling reports and action plans to improve results rather than focus on the work that was being done on what you might call the front line

Euan 5Euan 6

 

 

 

 

 

So peoples behaviours and energies have been shaped by the tools which we have created, or as Marshall McLuhan stated “We become what we behold. We shape our tools, and thereafter our tools shape us.”

Euan 7Has the NHS moved away from its roots and purpose, have we lost something of what we had in our communities that supported and looked after people and helped them to be resilient, to ask questions, to seek solutions to be all they could be.

What are we trying to create with ideas of personalisation, co-production and collaboration and does this truly present us with a new model for a way forward in the NHS given the huge challenges we face, how can we engage the public in a debate about making the NHS better, harnessing the people’s ability to be part of the solution.

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One example of this collaborative approach came following the announcement in June 2014 by the Cabinet Secretary for Health and Wellbeing, Alex Neil MSP, that: “… we must do more to listen to, and promote, the voices of those we care for. We need the voices of our patients, those receiving care and their families, to be heard in a much clearer and stronger way” the Scottish Health Council working in partnership with Scottish Government officials, COSLA officials, and members of the Alliance, have been doing work on the ‘Stronger Voice’. Locally the Scottish Health Council has responded to this by setting up a “people’s database” , a list of people who are willing to be part of public involvement and in a way suited to them eg. Email, focus group, online survey.

(Contact: dumfries.galloway@scottishhealthcouncil.org to get involved!)

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So clearly most would agree that working in the NHS is at times stressful, chaotic, and a complex arena, with no easy answers, we might wonder if we are making a difference, we might think of the old days when things were better or have our own ideas of what needs to be fixed. Sometimes these things may appear outwith our direct control or even our ability to influence, but sometimes just sometimes there may be times when are able to exert control and influence for change.

Euan 9.2A colleague I worked with some time ago would always say “don’t give me problems give me solutions” and one way of looking at solutions has been a key feature of a therapeutic approach called “solution focused therapy”

 

 

Euan 9.3The Solution-Focused model emerged from the therapeutic arena of Family Therapy in the 1980s. Since then, its psychological principles have been applied to a wide range of fields, from mental health to organisational change. The model reflects the values of co-production as it affirms collaborative, personalised, strengths–based values and a clear focus on sustainable outcomes.

The aim of a Solution-Focused approach is to help individuals, teams and organisations develop constructive, customised solutions. It is therefore solution-focused rather than problem-focused. So the term indicates where we look: forwards, towards solutions, rather than backwards, by studying problems.

The approach commonly begins with the miracle question:

So my thought for you is this:

In amongst all the things we have to do, the daily grind of serving and caring when things can sometimes be a bit of a bother, the things that irk, whatever it is that bothers you about working in the NHS here’s a miracle question for you

Suppose….You finish your day, go home, go to bed and eventually you fall asleep

….And while you are asleep a miracle happens

….And this problem has vanished or things are how you want them to be

…..But, you’ve been asleep so you don’t know the miracle has happened. As you

wake up – in the middle of the miracle – what’s the first sign you notice that tells you

things are now as you would like them to be?

What do others notice that is different?

What are you doing?

What are others doing?

What else is happening?

How are people responding?

What is the positive impact of this for you and other people involved?

What else do you notice?

Who else notices what is happening?

Euan 9.4

Feel free to share this with colleagues and allow yourself the opportunity to begin looking forward and not backwards

Euan McLeod is the Senior Project Officer for the National Bed Planning Toolkit