Tour de Finance by Jeff Ace

This summer, unlike the many thousands of fellow Welsh folk heading south to France for one of our regular appearances in a major football tournament, I decided to head west, then east, then sort of north east. Together with our Finance Director, Katy Lewis, I recently undertook a tour of the region to try to talk directly to as many staff as possible about the challenges we were facing and to hear first hand their experiences and ideas for improvement.

In three days we travelled over 400 miles, met over 400 staff and heard from nurses, AHPs, domestics, GPs, consultants and others on issues ranging as wide as the region itself. At a number of the meetings, it was great to see social work staff in attendance, reflecting our ever closer working relationships.

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I asked Katy to open each session with a presentation on the financial situation – my thinking being that pretty much anything I then said would come as light relief. The 2016/17 numbers are grim and substantially worse than anything we’ve faced up until now. In summary, we estimate our costs will increase by around £16.5M in the year (largely driven by drug cost increases and pay / price inflation) whilst the increase in our allocation for health services is around £3.6M. The gap between these figures of about £13M (or 5%ish of our running costs) will have to be found from efficiency savings. This would be a tough ask at the best of times but, as most of you will be well aware, it comes after four years of delivering large annual efficiency savings targets.
And of course the financial problem does not sit in isolation. In each of the discussions across the region we heard of pressures caused by difficulties in attracting staff or by increased service demand driven by an ageing population. At times it felt as though we were describing a perfect storm of crises in money, recruitment and demography that threatened to overwhelm us as surely as Storm Frank had submerged parts of Dumfries.

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But just as the pub in this picture was open for business only two days later (it felt longer), things often brightened up pretty quickly in a lot of our discussions. The staff that we met were keen to highlight potential solutions, things that could change services for the better and stand up to our triple challenge.
We’re going to write up the key points raised and create a plan for delivery but some of the common themes were;

  • The right I.T. can transform the way teams work, but we need to make it connect faster and more reliably across the region.
  • We need to get far better at sharing appropriate information between health, social work and third sector colleagues.
  • We need to be quicker at admitting that some vacancies won’t be filled and to redesign and retrain teams to provide services differently.
  • Local teams need to be empowered to make locally appropriate decisions and as much resource as possible needs to be devolved to operational levels.
  • Coordinated support to teams around improvement techniques and methodologies would be helpful.
  • We need to work more closely with carers and families.
  • We need to celebrate team successes and better spread their ideas and learning.

It’s also important to remember that we’re not on our own in trying to work our way through the financial, demographic and recruitment problems. In our meetings we highlighted some of the huge amount of work ongoing at national and regional level at the moment to try to identify high quality and more sustainable models of service delivery across Scotland. Two particular strands of work have the potential to help us transform the landscape;

  • The National Clinical Strategy (written by Angus Cameron, our Medical Director) sets out a clear direction for closer working between Health Boards aimed at improving safety and effectiveness of care within their wider region.
  • The Chief Medical Officer’s work on ‘Realistic Medicine’ points to how genuinely person centred care can lead to better patent outcomes whilst reducing waste and unnecessary expenditure.

So, both locally and nationally, there are grounds for cautious optimism that we can come through these uniquely challenging times in a way that allows our teams to continue to deliver excellent health and care services for our population. It is clear though that to succeed in this, the pace of change around redesign of service models and ways of working will have to be dramatic. Whilst there’ll be a few giant leaps (it’s just over a year until we receive the keys to our new acute hospital…) most of this change will be smaller scale and driven by the local teams that we talked with on our regional tour. Our success will depend on how well we support these teams and ensure they have the skills and confidence to adapt their services in ways that allow us to deal with the financial, demographic and recruitment complexities.
Thanks to everyone who came along to speak to us on our tour.

Jeff Ace is the Chief Executive Officer for NHS Dumfries and Galloway

The Power of a Fly by Heather Currie

Acceptably, an unusual title! The reason will be become clear but essentially, the message is that something very small can make a huge difference.

Following on from Ross McGarva’s blog last week on reducing waste and CRES, let’s look at how we as clinicians can make a difference. A recent report from the Academy of Medical Royal Colleges, “Protecting resources, promoting value: a doctor’s guide to cutting waste in clinical care” was published with the aim of supporting doctors and other clinicians to ensure that the resources of the NHS are used in the most effective way possible to provide the best possible quality and quantity of care for patients—one doctor’s waste is a patient’s delay or lack of treatment. (The report can be read by clicking here) The following is a summary of the key messages of the report with my observations on relevance to ourselves in Dumfries and Galloway.

It is becoming increasingly clear that use of NHS resources in the current form is unsustainable and without major changes the safety and quality of patient care will decline. Therefore waste must be reduced. Most waste within the NHS lies within clinical practice and models of care. Estimates suggest that around 20% of mainstream clinical practice brings no benefit to the patient as there is widespread overuse of tests, interventions, prescribing, hospital beds, clinics and theatres. According to a report in 2010, the cost of prescribed medicines wasted is estimated to be around £300 million each year. Influences that affect how a doctor uses clinical resources include:

  • Individual practices
  • Defensive practices
  • Time pressures
  • Responding to senior or patient pressures
  • Inefficient pathways

Before we explore some of the specific examples as discussed in the report, let’s have a think about our own experiences of the above non-exhaustive list.

Are you completely sure that you are following best practice, is it different from your colleagues, if so why? Could one of us be wrong?!

Have you ever arranged tests or started treatment “just to make sure” when, with full clinical assessment the likelihood of the test or treatment being helpful is very small? How often does a seemingly simple “routine” test lead to even further unhelpful tests?

We are all affected by time pressures and it may be a short term fix to ask the patient to come back another day to complete assessment/treatment when a little more time could prevent another visit.

Am I simply doing repeat tests to prevent being caught out on the ward round, even though it may not be clinically indicated? A recent spot check in our own hospital revealed that of over 25 blood form requests, very few contained any clinical details—what thought had gone into making these requests?

Are we making the best use of clinics, hospital beds, and theatres? Do we bring patients back to clinics inappropriately when we could write to them, phone them, or let them contact us directly if they have a problem? Do our clinics start on time and do we book the full clinic session? Are patients coming to the hospital more than once because of an inefficient pathway? Have you examined the pathway of your patients recently? Do we cancel clinics or theatres at short notice because of lack of forward planning? Every clinic which is cancelled with less than 6 weeks’ notice leads to at least 2 hours of time for Patient Focussed Booking staff to contact patients and rearrange appointments, let alone the inconvenience and reorganisation required by patients.

Do we ever ask patients to attend their GP to have blood tests, collect prescription, get results of tests that we have carried out or requested or to be referred to another hospital specialist? All of these can be done or arranged by ourselves in secondary care saving precious time for both patients and our GP colleagues.

With waiting time guarantees extreme pressure and scrutiny of pathways is constantly applied, especially to patients referred with suspected cancer. While this is to be applauded, time and effort is often wasted by leaving out the clinicians in the process; we know our services best and are able to adapt to accommodate urgent patients as required, talk to us not about us!

At all times, with every patient encounter, we should ask ourselves “Are there points of delay and waste in any stage of the process due to duplication, lack of resources or availability of information, or inefficient use of clinical and patient time. Could we do better?”

Specific areas of waste discussed in the report include prescribing, inappropriate investigations, staff and patient movement, maximising capacity in theatre, and reducing inappropriate interventions.

Reducing prescribing costs

GPs are well aware of need for generic prescribing, and use of low cost options, but are we as aware in secondary care? With increasing provision of prescriptions from clinics for reduced inconvenience to patient and GP, we in secondary care also need to be aware of cost and generic formulations. Why not develop a list of commonly prescribed medicines in generic form to have available in clinic?

Reducing inappropriate laboratory investigations

Blood tests

CRP testing has risen dramatically in recent years with many patients now being subjected to daily measurements even if levels remain low. National benchmarking showed a 31% increase in CRP requests over 1 year in one region. Disease related protocols were agreed and requests reduced by 85%. Minimum re-testing interval for CRP of 3 days, with exceptional requesting still possible and overseen by a senior clinician, was introduced in Borders leading to reduction in testing of 30 to 40%.

Minimum re-testing interval for Vitamin D of 1 year led to reduction of 50%.

Minimum re-testing interval for HbA1C of 3 months led to levelling off of rising trend.

Local experience–Patients presenting with infertility have frequently had blood tests taken for renal, liver, and thyroid function along with hormone profile, androgen screen and prolactin despite the woman having regular menstrual cycle. With a regular, 21 to 35 day cycle in a clinically well woman, significant renal, liver, thyroid, hormone, androgen or prolactin problem is extremely unlikely. Provision of information to primary care colleagues and publication of infertility assessment guideline to easily accessible Guidelines area on HIPPO should reduce unnecessary tests.

Does your specialty have similar examples of inappropriate tests being taken before referral for which guidance could be made available?

Imaging

Some radiological investigations contribute little to clinical management, particularly lumbar spine and knee radiographs. Guidance notes provided alongside the report of every relevant radiograph reduced referrals for knee and lumbar spine radiographs by 20%. If applied nationally this could save £221 million per year (presumably in England). While we are working towards improved MSK pathways in Scotland, are all imaging requests absolutely required? In gynaecology we often find that a scan for an uncertain reason leads to further scans due to the finding of a probable insignificant feature.

Staff and Patient Movement

Separate sites for outpatient clinics increases travel time and reduce numbers of patients that can be seen. While recommendations encourage clinical care to be closer to home, rethink of use of peripheral clinics would be reasonable. Review of reasons for clinic appointment, especially return appointment and increasing use of telehealth clinics (telehealth incudes option of telephone follow up) and video-conferencing is already taking place in D & G.

Maximising capacity in theatre

Each week around 15 to 18 hours of theatre time is wasted due to late starts. Many late starts are significant and recurring. While the majority of patients are now admitted on the day of theatre instead of the day before as in the past, do we plan appropriate time and do we use space efficiently so that patients can be seen before theatre early enough and theatre starts on time? Occasionally cases are cancelled on the theatre day because the operation was not needed—have we ensured that the patient was fully assessed before theatre by a senior doctor?

Reducing inappropriate interventions

Many interventions may be unnecessary or harmful. NICE “do not do’s” identifies clinical practices that should be either discontinued completely or not used routinely. Are we sure that we have studied areas relevant to our speciality? To read the NICE document click here.

To conclude, while at times it feels like we are all working harder and under greater pressure than ever before, there are small changes that we can all make. Much of this article refers to the practices and actions of doctors, but hopefully there is something of relevance to everyone. Just take a few moments to think about our practices, tests, pathways, processes, and most of all, what is best for each patient.

Heather Currie 1

To finish on a light-hearted, but pertinent point and to explain the significance of the title, the urinal shown above was developed at Schiphol airport to include a fly in the basin. This simple act reduced urinal spillage requiring frequent floor washing by 80%, proving beyond doubt that simple changes can indeed make a huge difference.

Heather Currie is an Associate Specialist in Obstetrics and Gynaecology and is Clinical Director for Women and Children at NHS Dumfries and Galloway

 

CRES and Our Collective Responsibility for Waste by Ross McGarva

As an accountant and a Scotsman I’m well aware of the stereotypes around being tight fisted and penny pinching. In fact, I’m quite proud to admit I fit in with that particular stereotype, although ‘proud’ is not the word my better half would use to describe me! However, in recent years it has become more socially acceptable to be frugal or thrifty. The economic situation over the last few years and an increase in environmental awareness around our own carbon footprint has increased the need to reduce waste and live within our means. This is evident with the rise in popularity of budget supermarkets, Martin Lewis, extreme couponing and the ‘bag for life’, to name but a few.

Ross M 1So what’s this got to do with the health board? I wanted to talk about waste and CRES or Cash Releasing Efficiency Savings and how the responsibility sits with everyone employed by the board and how it’s not really a million miles away from what we do every day at home. 

 

Financially managing a health board is similar in some respects to financially managing your household. We all have to manage our household bills and outgoings to live within our income budget. If your outgoings are more than your income then you have a problem, one of the solutions being to reduce your expenditure.

In terms of the health board, in the current financial year we received a 2.7% uplift in our annual budget allocation, the equivalent to about £7 million. At the same time our expenditure has increased by £14 million (made up of incremental uplifts, pay awards, 7% drugs inflation, general inflation, etc). In order to balance the books we need to save £7 million which we look to achieve through CRES. Although the responsibility for formulating the CRES plans sits primarily with the General Managers, everyone, as an employee of the NHS, has the responsibility to use resources efficiently and to avoid waste.

There are a number of concepts and theories around waste and lean working, the majority of which originate from the Toyota Production System and relate mostly to manufacturing. However one of these concepts can be applied to the healthcare environment and even your own household. This concept is known in Japan as muda (無駄) which is a term for anything that is wasteful and doesn’t add value and if you’ve ever heard Jason Leitch (Clinical Director of The Quality Unit, Scottish Government) talk about finance then you may be familiar with the notion.

Jason does however warn that once you’re aware of the 6 concepts of muda you will start seeing waste everywhere. This may lead to you become as annoying around the house as I am. The 6 categories of muda are: 

  1. Ross M 2Delay – idle time spent waiting for something such as appointments, test results, reviews, spare beds, late starts to theatre or clinics or even meetings that go on longer than they should. Under utilisation of clinic spaces so delaying time for appointments. How often do you wait around picking your kids up from their various after school clubs and hobbies? 
  2. Ross M 3Re-work – performing the same task a second time, re-sending, re-scheduling, late cancellation of clinics or theatres, repeating questions, multiple bed moves, performing multiple diagnostic tests. Re-laundering clean towels or linen. Or cleaning the kitchen floor at home only for the dog to run through with muddy paws 
  3. Over-production or Over-servicemanufacturing of products or information that is not needed, such as precautionary “defensive” medical tests, “routine” blood tests taken without considering clinical value, inappropriate imaging which then leads to findings of clinically insignificant features, leading to further imaging… surplus medications, excessive levels of paperwork. For example, at home – your subscription TV package, how many channels do you actually watch?Ross M 4
  4. Ross M 5Movement – the unnecessary transport of people, products or information, such as requiring patients to see a primary care provider before seeing a specialist who is clearly needed. Asking patients to attend their GP for investigations, results, prescriptions when these can be arranged while the patient is in secondary care. The unnecessary movement of patients between wards. Requesting patients to attend a hospital clinic when a phone call or letter would provide the same information. At home – driving the kids to school after they’ve miss the bus.
  5. Ross M 6Defects – design of goods that do not meet customer needs such as medication errors, wrong side surgery, laboratory labelling errors and clinical errors.
  6. Waste of Talent, Spirit and Skill – failure to address the many hassles in everyday life, hunting and gathering, re-calling, the same things every day. Making decisions without the involvement of the whole front-line team so missing valuable contributions. People disengaging due to lack of feeling valued and appreciated. I’m sure we can all relate to this at some point.

Ross M 7As you can see, waste is everywhere. The real challenge is highlighting it and coming up with a solution to tackle it. One of the most prominent messages I’ve came across as a regular reader of the blog is ‘the standard you walk past is the standard you accept’. This is an incredibly powerful comment particularly in context with patient safety and quality but the same also applies to waste and protecting the valuable resources we are so privileged to have access to.

The CRES challenge is huge but if we can all remove some of the waste from our day it can soon add up to a realisable tangible benefit. For example, it only costs the board £0.43 to launder an item such as a towel or a pillow case but we launder nearly 2 million items per year at a total cost of nearly £800,000. Even something as small as segregating waste properly has an impact. The disposal of clinical waste costs £400 per tonne compared to £100-£200 per tonne for normal waste – last year it cost £216,000. It is estimated that around 50% of waste is subject to incorrect segregation. Assuming we could divert even 20% of our clinical waste into black bag stream domestic waste, we would save around £30,000 per year.

So as the old thrift saying goes, look after the pennies and the pounds will look after themselves. On that note I’m off home to turn down the thermostat.

Ross McGarva is a Management Accountant at NHS Dumfries and Galloway

 

 

 

Quality versus Finance – Do the grey suits run the NHS? by @katylew38

Katy Lewis 1Having been motivated by the inspirational weekly blogs I decided to put pen to paper with much trepidation as to whether the ramblings of an accountant would even vaguely interest the usual readerships of the weekly instalments. I’m not saying I was born an accountant, but my aptitude for maths was identified at an early age and made my career path inevitable

Katy Lewis 2My introduction to the NHS in England was as a Management Accountant at a time when NHS Trusts were multiplying rapidly and the job market for NHS accountants was on the increase, which was lucky for me given I needed a job and I thought altruistically I could make a difference working in the public sector as oppose to commercial entities. That was 22 years ago and as we know the NHS has had many a restructuring, reimagining and reinventions since then, with my move to Dumfries in 1998 triggered by the latest iteration at that time.

Katy Lewis 3Having decided to move here for a couple of years and accepting my chosen career as an accountant which came out of my ability in Maths, a dad who was a bank manager and saw it as a “safe job” rather than a burning ambition and was pretty much set when at 5 years old I had my first responsibility of collecting and adding up the school dinner money. The move to Dumfries proved to be an excellent but incredibly challenging career move for me and 16 years later, recently appointed to Director of Finance, it appears I’ve settled here for good!

Katy Lewis 4The role of the accountant within the NHS has changed unrecognisably since I put on my first “grey suit” with the role these days much more focusing less on the “bean counting” and much more on the business partnering, added value role with the finance manager a key team member alongside the General Manager, Nurse Manager, Clinical Leads in supporting the decision making processes of the organisation.

I firmly believe that finance must earn its “keep”, we are a support function and are continually challenged to demonstrate it worth and value we provide to the organisation beyond the “technical” functions we provide and that our key role is as enablers to support the critical decision making within the organisation. But also to provide that critical friend role, to challenge outcomes, decision making to ensure that we haven’t been lazy in reaching an end point, that we have considered all alternatives, come up with new ideas and provide an important and different viewpoint to the argument being presented.

As Director of Finance I have a clear leadership role in the organisation and as defined by the Healthcare Financial Management Association (HFMA) in their publication “the Role of the Chief Finance Officer 2013” described the role under four main headings:

  • Corporate leadership
  • Stewardship and accountability
  • Financial management
  • Professional leadership and management

 The role is not just about balancing the books (although that is an incredibly important part of the job!) but engaging as part of the leadership team and taking corporate responsibility for decisions which the Board makes.

You will all be familiar with the publication last year of the Francis report and this has been considered very seriously by finance professionals given the concerns about the focus on financial issues to the detriment of quality of care.

Katy Lewis 5The HFMA published their response to this report which reminded financial professionals of their responsibilities to operate in a professional manner at all times and highlighted the following points:

  1.  All NHS finance staff should remind themselves of the contents of the codes of conduct of their professional bodies, employing organisations & NHS constitution and adhere to them
  2. All governing Board members are equally responsible for quality, patient safety and financial performance of their organisations
  3. All NHS finance staff should understand how their role supports the achievement of organisational objectives & delivery of high quality patient care
  4. NHS finance staff should provide the most up to date, reliable, useful and complete financial information possible and aim for the highest standards of financial probity and financial reporting
  5. A focus on knowing the business and understanding the finances will lead to better services for patients
  6. Finance staff have a duty to promote the best use of resources and the achievement of value for money

 Katy Lewis 6As finance professionals this has reminded us of our responsibilities beyond the just the money and we can’t just drive financial efficiencies at the expenses of everything else and our professional and ethical codes supports this approach. The focus in NHS Scotland is driven by the quality strategy at the heart of what we do and to use this to drive improvements in person- centred and effective care. The engagement we have as financial professionals with clinical staff must reflect this, recognising that understanding the clinical challenges and engaging on quality and efficiency improvements can lead to a much more productive and constructive outcome for all involved.

Since the downturn in the economic position in 2008 the need to deliver efficiencies to balance the books has been an important consideration. We are clear that finance forms one of the four dimensions of our thinking along with our workforce, quality and service issues. None of these are more important than each other overall and we must take use a balanced approach to this and keep the patient at the centre of our thinking to ensure we come to the best decision. The focus has to be on quality driven financial management. Do we believe that if we get the quality right the financial efficiencies will follow?

Katy Lewis 7

Katy Lewis 8As we move into what are set to be an incredibly challenging few years with the building of the new Hospital, Health and Social Care Integration and the demographic and economic inevitabilities, we must to focus on the opportunities, and continue to trust the people in “grey suits” to support us to make the decisions we need to make as an organise and to value/ develop the role within the clinical teams.

 Footnote: although a reference the term grey suits to mean accountants neither myself nor most of my team conform to the stereotype     

Katy Lewis is the Director of Finance for NHS Dumfries and Galloway

Clinical Care and the Financial Challenge – How do we Respond? by Mike Pratt

MP 1When I was at school I was uncertain of what I wanted to study at university.  Two front runners were Accountancy and Pharmacy.

Obviously I chose Pharmacy, and I have been very pleased with that choice.  This profession has given me opportunity to carry out work that has greatly satisfied me and hopefully has provided some benefit to many patients and I have tried to help other members of staff along the way.

 

However the job is changing and I did reflect to someone recently that I am beginning to feel as much like an Accountant as I do a Pharmacist. 

 

This of course is partly because the NHS, and the country, is in financially difficult times.  We also have an aging population which brings with it increased health challenges.  But it is also because we have seen some very major advances in medicines, some of which come with a huge price tag.  In particular the introduction of highly effective biologic preparations, with very specific and targeted drug action.  This is the result of some very sophisticated science, of which I am struggling to maintain my understanding.  Indeed when I read of a future where big pharmaceutical companies are involved in licensing stem cell products to treat a range of conditions including cancers, cardiovascular diseases, CNS disorders and diabetes, I start to feel well out of my depth.  And I dare not even consider the cost of these treatments. 

MP 2Couple this with emerging work in the area of genomics and stratified medicines where vast amounts of clinical, lifestyle, environmental, genomic and biological data is collected for a patient, allowing us to move to individually tailored treatment and therapeutic strategies.  We move away from standardised medication dosing towards made-to-measure medicines.  It is believed this approach will improve the lives of millions, of chronic disease patients.  If you are struggling to understand any of this, don’t worry my brain is starting to melt at the thought of it!  But again it will not be cheap!

 

The new biologic medicines we currently have, have revolutionised care.  In ophthalmology we can now stop some patients going blind with a regular injection, in rheumatology we have greatly improved the lives of arthritis patients, we have reduced the number of relapses multiple sclerosis patients experience and significantly reduced their MP 3rate of deterioration and we have improved the survival rates in a range of cancers to name but a few of the care benefits.  But whilst as a healthcare provider we rightly celebrate these successes, the down side is they come at a huge cost at a time we have little money.  This Board I have to say, has done extremely well to find funding for these medicines. This should be recognised and applauded.  But if we have a financial challenge now, then a glance to the future is clinically exciting but financially frightening!

 

So how do we deal with a future that comes with seemingly endless opportunities to bring clinical benefit and yet no significant increase in the resource we have to deliver this?

 To a large extent my answer is  – I don’t know!  But I do know we can’t expect our Finance colleagues to continually bail us out.  We are all in this together.

 There are some common sense steps we can take to increase the effective resource we have.  Simple steps that we are doing, but must continue to do with increased vigour:

 Reduce waste at all points of the health system

 There is not much waste nowadays I hear you say.  Well research carried out by the University of York indicates around 10% of medicines prescribed are wasted.  For us that means that with a budget of around £40m, perhaps as much as £4m is wasted.  So there is work to do.

 I also need to highlight that if there is 10% waste in a reasonably controlled process such as prescribing, what waste is there elsewhere? 

 Whatever you use, use it properly

 Research has shown that around 10-20% of hospital admissions are associated with medication related incidents.  By developing models of working across the whole care team including the patient we can improve on this greatly. 

Use the most cost effective products

In prescribing we have made many great improvements in this area, with a high level of adherence to prescribing policies.  We could however still improve, we need to challenge each other on this.  We also need to look at all areas of healthcare and feel free to challenge each other.

All these above are very important and will help us to sustain our position for a little while.  But the scale of the challenges we face in the future will not be dealt with by good housekeeping.  We need to consider some more fundamental changes.  This we cannot do alone.  There are 2 other issues I think we need to deal with as a priority.

 Understand and Work with Our Population

We need to work with our patients and with our population to determine what they want and need.  It might be surprising!

 

Research carried out by respected organisations, such as the Health Foundation and the Picker Institute has shown that the patient and the population can take a very mature and sensible view about healthcare priorities.  Indeed it has been demonstrated that affordability is a factor that citizens recognise as being important, as long as they can also have an opportunity to influence decision making.

 

Research by the Centre for Health Economics & Medicines Evaluation in Bangor also showed that the public had some very clear views on priorities and for example were not prepared to pay more for medicines that prolonged end of life, treated children, rare conditions or disadvantaged populations.

 

Whilst this is very interesting, all it says to me is that we need to understand our population.  We need to ensure that when the real difficult times come, we are all working together with a clear agenda.

Finally we must:

Change the way we do things

MP 4One of the great things about NHS Dumfries & Galloway is that it is full of good people, who are great to work with and are reasonable.  We make reasonable decisions.  However I am reminded of a quote by George Bernard Shaw:

The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man.

 

As we approach truly difficult times perhaps we need to encourage the unreasonable man (or woman).  We cannot keep on doing what we are doing and expect a different outcome.  We need radical change, and we need to do this in partnership with our population.  So come on stop being so reasonable!!  Lets challenge ourselves to deliver things in a different way to allow us to benefit from an exciting future.

Mike Pratt is Chief Pharmacist at NHS Dumfries and Galloway