Honest Reflections by Barbara Tamburrini

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

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

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

 

‘It’s not my fault.’

‘It’s not fair.’

‘I want that.’

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

 

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

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

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

Anne 1The more society gives in terms of allowing individuals to renege on any personal responsibility and the more it protects them from the consequences of their actions and decisions the deeper into this complex and costly moral mire we sink.

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

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

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

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

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

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

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

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

Anne 2So how do we start to change things and find that balance between a society that takes care of its vulnerable and needy and yet engage differently with those who are outside of the vulnerable and needy group but still think they have the right to whatever they want at whatever cost – as long as it is not to their pocket or life style.

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

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

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

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

Fire in your belly by Euan Macleod

Euan 1

What is the fire in your belly?

Euan 2When it comes to what you do? Do you feel passion for it and are you excited about the possibilities that could come your way, or is it a bit like the guys with the Gaviscon have just hosed you down and your fire is quelled?

 

 

Fire in your belly-you know when you’ve got it

You feel it

Euan 3Sometimes it is hard to find time to listen to our feelings in the midst of busy work schedules, the passion that you first felt when you entered a career in the NHS may have become blunted by the daily trudge-is it always going to be like that?

I recently mentioned in a blog the creation of the NHS and the welfare state.

Beveridge had a passion for that, but where did that passion come from?

Beveridge’ report might have been destined to be another dry and dusty Government document. What made it a huge public best seller was its breathtaking vision and passionate language. The fiery rhetoric largely came from Scotland after weekends spent with Jessy Mair in the spring and summer of 1942.

Jessy was Beveridge’s close confidante and companion for many years. His biographer, Jose Harris, highlights her influence on him during his visits north of the border:

“Much of his report was drafted after weekends with her in Edinburgh and it was she who urged him to imbue his proposals with a ‘Cromwellian spirit’ and messianic tone. ‘How I hope you are going to preach against all gangsters,’ she wrote. ‘who for their mutual gain support one another in upholding all the rest. For that is really what is happening still in England’. . . .”

Beveridge didn’t miss; the report sold 100,000 copies within a month. Special editions were printed for the forces.

The gangsters referred to by Jessy Mair were the deliverers of health care who profited from the sickness, squalor and disease prevalent at that time. Beveridge clarion call to a sense of community welfare based on need and not ability to pay heralded the start of the NHS.

No surprise that today many of us remain passionate about the values and aspirations of the health service, a service that many of us have experienced as employees, patients and carers of loved ones. There is still some fiery rhetoric and a will to retain and improve on the values and service which the NHS provides.

But it won’t be easy in this time of austerity.

Euan 4

It might need

Guts-More fight

Grit-More passion

Gumption-Being courageous

Euan 5

It means that you find a way to get better

It means that you’re putting in every ounce of extra effort you have

It means that you get pushed down but don’t stay there

Euan 6

Easy to say

Perhaps harder to achieve

But unstoppable when it starts

Euan 7

So what’s your passion and where is it taking you? Share the fire in your belly, it could start a bonfire

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

 

 

 

 

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.’

Leadership in a rewarding, complex and demanding world by Paul Gray (@PAG1962)

The people we serve – the people who live in Scotland, and visitors too – have high expectations of us. And so they should. We operate in a complex and demanding environment, but NHS Scotland is a successful organisation, delivering to high standards of timeliness and quality, and always seeking to improve. The people I meet work day and night, every day of the year, to deliver compassionate care, and whole range of ancillary and supporting services from health science to finance to laundry. And the rewards of speaking to someone whom we have been able to help, who expresses their thanks and wants to emphasise how much they appreciate the care they have received, can’t really be quantified.

Some facts and figures might help. What are we actually delivering each year, with a workforce of over 150,000, and a budget of £12bn, serving a population of 5,295,000?

  • Over 24 million GP and practice nurse consultations
  • Over 450,000 acute day case procedures
  • Over 1 million acute inpatient procedures
  • Over 1.6 million A&E attendances
  • Over 4.6 million outpatient attendances

And we have over 4.7 million patients registered with an NHS dentist, and real progress on improving oral health in children through the Childsmile programme. Pharmacy is developing too, with services being introduced including Minor Ailment Service (MAS), Public Health Service (PHS), Acute Medication Service (AMS) and Chronic Medication Service (CMS).

We’ve also made considerable and measurable progress on patient safety through the internationally recognised Scottish Patient Safety Programme. Our most recent data show a 16.1% reduction in Hospital Standardised Mortality Ratios since the implementation of the Scottish Patient Safety Programme in 2008; and cases of C.Diff in patients aged 65 and over are at their lowest level since monitoring began.

We are integrating health and social care, so that more people can be supported to stay at home, or in a homely setting – some of whom might be quite unwell, with complex conditions. That means different ways of working, with a range of partner organisations, while maintaining our focus on safe, person centred, effective care. And Sir Lewis Ritchie is leading a review of Primary Care out of hours services, which I am sure will offer some important recommendations on the way we structure and provide unscheduled care. The demographic trends we face are well known to us – we do have an aging population, with increasingly complex health conditions; and there is clear evidence that people generally have better outcomes, and are happier, when they can be cared for at home. Indeed, it’s worth remembering that although there is clearly pressure on General Practice, 87% of patients say that the overall care provided by their GP surgery is good or excellent.

When people do need to come to hospital, we work hard to treat them within the standards we have set, whether that’s to see and treat 95% of people within 4 hours of attending an Emergency Department, or to deliver treatment within our 12 week Treatment Time Guarantee. We’ve made considerable progress on getting to the 95% A&E target across Scotland and I’m grateful for that – but I do know that there are peaks in demand, and that patients are tending to present with more serious and complex conditions. And I know that some specialties are finding recruitment tough, which adds to pressure, but we should also remember that 89% of Scottish inpatients say overall care and treatment was good or excellent – which is highest figure since surveying inpatients began in 2010.

We continue to look critically at ourselves, through a combination of internal assessment and governance, and external assessment through Healthcare Improvement Scotland, and Health Environment Inspections. We don’t pretend that we always get it right, and when we don’t, we act systematically to understand the issues and to implement the changes we need to make with purpose and commitment. And we learn too from reports from elsewhere, like the recent report on maternity and neonatal services in Morecambe Bay, to which our Chief Medical Officer, Catherine Calderwood, contributed, and earlier reports such as those on Mid Staffordshire, including the report “A promise to learn – a commitment to act” to which our National Clinical Director for Healthcare Quality, Jason Leitch, also contributed.

Paul Gray 3So what does this mean for leadership in the face of complexity and increasing demand? What does it mean for leadership when often the external narrative – whether in print, broadcast or social media – focuses on problems, and gives less recognition to the things that are going well or improving? I offer the following suggestions. It’s drawn from my own experience of the things that have worked for me, so in that sense it’s personal. But I hope that it prompts you to think and reflect, or to have a conversation with someone. If it did, that would be great.

  • Ask yourself if you can describe what you do, and the outcomes you need to achieve, simply and clearly in a few sentences. If you can do that, it helps you and those around you to understand how they fit in to this complex world.
  • Remind yourselves and those around you of what we do well. Take time to recognise success and to praise a job well done.
  •  Build on what we have – almost all of the people I meet are proud of what they do, and want to do it better.
  •  Remember that leadership is about proactive actions, not job titles. Some of the best examples of leadership I have seen include:
  •  the porter who realised that a patient was upset, spoke to her about how she was feeling, made the staff on the ward aware, and got her a cup of tea. In her words, “He turned my day right round”;
  • the receptionist who realised from the questions asked by visitors that the signage somewhere in the hospital was misleading, went and found the misleading sign, wrote out some better wording and gave it to her colleagues in Estates.
  •  Be open to feedback. Seek it out – and don’t be afraid to reflect on what you hear. Don’t be afraid of external scrutiny either. It can be tough, even painful at times, but better to learn, improve and grow than to stagnate and provide a service that is less good than it could be, or to put patients at risk.
  •  Learn all the time. Encourage and support others to learn. Learn from the best, as well as learning from what went wrong.
  •  Have honest conversations. Don’t let issues fester until they create a real problem. Prepare for these conversations. Good conversations don’t often happen by accident.
  •  If there is an issue or a problem, describe it specifically, and think carefully about the best way to tackle it. Ask yourself if there’s a contribution you could make to the solution.
  •  Uphold the core values of the NHS. If you see or experience inappropriate behaviour, such as bullying or discrimination, speak up, or seek help to address the issue. Don’t let it slide, or suffer in silence.
  •  Think about what the complexity and demands mean for the people in your teams. Acknowledge the situation when things are difficult, or the going is tough. People appreciate honesty, and see through hyperbole.
  •  Ask people for their ideas about how best to tackle problems. They will have some amazing ideas – I promise you!
  •  Leaders take advice and ask for help. They know that they don’t know everything. They recognise and value that expertise that others have. So don’t become isolated, especially when times are tough.
  •  Involve others in decisions – especially in decisions that are about them, or affect them in some way.
  •  If you’re wrong, say so, and apologise. Be transparent. It’s not weakness to admit a fault or a mistake.
  •  Understand the people who work with you, for you and around you – including people who work in different organisations, who might have a different governance context, face a different set of pressures or demands, and use different language from that used in the NHS. They will appreciate that, and if you understand people and their motivations, it’s far easier to be influential. People are far more likely to listen to you if they know that you understand their perspective.
  •  Be someone who offers more often than they ask.
  •  Be someone who gives credit to others, and doesn’t seek it for themselves.
  •  Be persistent and methodical – if something is right, don’t be deflected by setbacks and criticism. If you have considered a course of action carefully, listened to advice, and considered the evidence, follow it through. In a complex world, people value leaders who keep a steady course, and don’t chop and change every day. However, if the context or the evidence changes, review your course of action. Persistence in the face of adversity is good leadership. Dogged pursuit of an outmoded idea isn’t.
  •  Look after yourself. Build and develop networks of people you can consult and talk to when the going gets tough. Take time off, and take a bit of exercise. Make time for family, friends, and things you enjoy outside work. Easy to say, I know – but we do need to restore our energy and keep our perspective. We give our best when we are at our best.

Paul Gray 1And finally – a big thank you from me. I am both proud and humbled to be associated with NHS Scotland. I am proud of the work we do, and of the people who do it. We have a great privilege to serve patients, their families and their carers, and a strong and shared commitment to do it well.

 

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

 

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

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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?

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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