Clinical Efficiency by Ewan Bell

In a previous blog (“Prioritisation in NHS Scotland” – November 2015), I opined that ‘we can’t continue to provide the current range of interventions and services, if we want a sustainable NHS for the future.’ In other words we really need ‘to start debating and defining the essentials of health-care and what can we pull back from’. I had numerous comments and emails from colleagues; the majority supportive of my view. Since then there have been several blogs, including Chris Isles (“Time to Prepare for our new Hospital” – December 2015), Catherine Calderwood (“A Message from the CMO” – February 2016) and Anne Marshall (“Rights without Responsibility – Where are we Going?” – August 2016). These, in some way, have all informed that debate.

Chris believes ‘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’.

I think he is wrong and here’s why. Year on year from 1997 to 2013, the UK has spent more and more on healthcare. Below is the most up-to-date data I could find from the Office of National Statistics.

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Currently (2016-17) the UK spends approximately 18% of its overall budget on healthcare – about £143 billion (total UK expenditure is £784 billion). If our answer to the increasing demand on our current health service is to keep increasing the amount of money that we spend on it by the same factor (x2.97) every 16 years, then by 2033 we’ll be spending approximately 52% of our country’s overall budget on the NHS, squeezing out spending on education, pensions, social security and defence. Now I know that Economists will laugh at the simplicity of this argument (fair cop I say) as I haven’t taken into account rising GDP (if it does post-Brexit), but my point is that there is never going to be enough financial resource in the NHS to meet an ever increasing demand (and nor has there ever been).

The recent Chief Medical Officer’s Annual report ‘Realistic Medicine’ and the National Clinical Strategy (NCS) 2016 raise several fundamental questions, which include:

How can we further reduce the burden and harm that patient’s experience from over-investigation and over-treatment?
How can we reduce unwarranted variation in clinical practice to achieve optimal outcomes for patients?
How can we ensure value for public money and prevent waste?

The context to these questions is described in the NCS:

“Value-based healthcare is an established approach to improving healthcare systems across the world – the central argument is that higher value healthcare is not necessarily provided by higher inputs. What matters more is that care is provided early in disease to prevent progression (avoiding the added patient burden of more intensive interventions), it is provided safely to avoid harm, it is proportionate to the patient’s needs (avoiding the waste of providing outcomes that are not relevant to the patient), it is provided consistently and reliably (avoiding unwarranted variation).”

“Over-treatment, wasteful treatment and variation is a broad subject, and an important one. It is important that it is addressed in Scotland so that we can be more confident that the use of resources is targeted to producing outcomes that matter to patients.”

So the national conversation has started. How do we ensure value for public money? And how can we be more confident that the use of resources is targeted to producing outcomes that matter to patients?

Do we systematically, and with rigour, evaluate and rank the clinical value of new drugs, new devices, new clinical guidelines or new procedures? No we don’t, but we should and if we are going to invest in a new intervention with significant clinical value, how are we going to afford it?

Part of the solution might be for each of us to start looking at our own clinical practice in terms of over-treatment, wasteful treatment and variation. Does our rate of intervention vary significantly with the national mean, and if so, is this variation warranted or unwarranted? Is there any part of our clinical practice that we do, because it’s always been done this way, but actually it really doesn’t benefit the patient?

There is already a lot of good work going on in Dumfries and Galloway looking at waste and variation. The Surgical team, led by JK Apollos and Stuart Whitelaw have recently been looking at the clinical value (there’s very little) of routinely sending sebaceous cysts and lipomas to Pathology. What about gall bladders? Heather Currie, Ranjit Thomas and Kim Heathcote and other clinicians meet regularly (the lab demand-optimisation group) to put in place measures to reduce wasteful and thoughtless laboratory requesting (do you know that the blood sciences lab processed 40,000 thyroid function tests last year)? This is not just about money. Over-requesting of lab tests can often result in the clinical pursuit of minor, insignificant abnormalities, which can lead to over-investigation of patients and on occasions harm.

There are lots of opportunities here to improve patient care and start to tackle some of the issues raised by the CMO and NCS. I have been asked to start looking at waste and unwarranted variation here in Dumfries and Galloway and hope that you will help by considering the real clinical value of all that you do and identifying clinical waste.

Ewan Bell is a Consultant Biochemist and is AMD for Clinical Efficiency

The beat goes on by Julie Garton

Music has the power to help improve quality of life for people living with dementia and their families. It can bring back memories, open up conversation, improve mood, restore calm and strengthen the person’s sense of self and relationships
There are around 90, 000 people living with dementia in Scotland and we have a responsibility to find and employ strategies and interventions that help people to live well with dementia
A key part of my role is to encourage and support the use of strategies and interventions that can increase wellbeing for people with dementia. Dementia is characterised by progressive and irreversible memory loss, and often verbal communication and thought processes deteriorate to such an extent that it interferes with daily life and activities.
The charity, Playlist for Life, aims to spread the word about the benefits of music and to help families and carers build playlists of personally meaningful music for their loved one. Founded in June 2013 by journalist and broadcaster Sally Magnuson, after she saw the impact that music had on her mother who had dementia.
Sally researched the neurological effect familiar music had on the brain, and found a growing body of evidence to support the use of personal music for people with dementia, and an American organisation, Music and Memories, who had discovered the most amazing results after introducing personalised music on iPods for people with dementia.
So, while it was obvious that ‘live ‘music could bring bouts of joy and sudden flashes of memory to people, the effect on individuals was transient. But playlists on an iPod, this was personal. This could go through life with you.
Please check out the website Playlistforlife.org for more details, but already, people have been reconnected to their loved ones and that elusive thing, their ‘ selves’ through sharing their music from their past on an iPod.
Music is the first and last channel of communication. Our auditory system is the first to fully function, even at 16 weeks in the womb we can hear and respond to music. It’s recognised that babies as young as 5 months can distinguish between happy and sad songs.
This forms a soundtrack to our lives. We can remember words and tunes to music and songs that we may not have heard for a very long time, but often the first few notes are enough to prompt a flood of memories, emotions and/or bad dancing in the kitchen.
In dementia, musical communication remains strong while often other forms of communication fade. Music can help those living with dementia connect with their past and their present. The brain structures involved in processing musical information often remains intact

The Benefits of music in dementia
Speeds healing – early healers used incantation and the Egyptians used music to treat a range of disorders
Increase optimism
Decrease pain
Reduce isolation
Reduce stress and distress
Promote active engagement & communication
Increase affection, creativity and expression
Reduce anxiety and depression
Increases co-ordination of motor movement, especially if combined with dancing

There is growing evidence that listening to music can stimulate seemingly lost memories and may even help restore some cognitive function. Not to mention, music engages the areas of the brain involved with paying attention, making predictions and updating events into the memory. Research suggests that even as dementia progresses, the brain has the ability to make neural connections which allow the person to reconnect with memories and emotions and expression. This provides an opportunity for families to share experiences and maintain a relationship with their loved ones, and can make visits easier and more meaningful.

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This is simple, easy and cheap. Where we can use personalised music, why wouldn’t we? When it’s effective, there’s not a dry eye in the house. I’m not sure if the days of forced communal listening to Daniel O’Donnell /Val Doonican/Scottish Country Dancing music and the like are over- I am emotionally scarred by years of Jimmy Shand and his band, (apologies to fans of the above) played relentlessly in older people s wards over the course of my career, but iPods are the way to go folks! Other Mp3 players are available.
Working in dementia care is fascinating, motivating and can give those working in the field a huge sense of satisfaction, but we have a long way to go before we have really got to grips with how to prevent stress, manage distress and ensure people are receiving consistently high quality, person centred care. Using personalised music is just one small way to work towards those goals, but a good one.
We had a training day in June for 15 members of staff from across the region. Staff from community hospitals, Midpark Hospital, community hospitals and palliative care attended and the impact of the training was tangible.
Staff will work with families to create personalised playlists for their loved ones. Favourite songs of course (and make sure the artist is the identified, we all have a favourite tune that’s been ‘covered/ruined’ (delete as appropriate) ), but other favourite music such as, nursery rhymes, TV theme tunes, Christmas songs can all help build the music to that persons’ life .
It also allows staff to deepen their knowledge of the person, allowing developed and enhanced relationships between staff and families and helps promote the use of This is Me as yet another tool to really get to know the person we are caring for.
My gratitude to League of Friends for their generous donation to buy a number of starter kits (iPods/earphones/splitter cables) and also to the IT department who have been hugely supportive, overcoming the technical challenges (and technophobes!) Thanks also to the Mental Health, Psychology and Learning Disability Directorate for enabling the training.
‘It took a lost weekend in a hotel in Amsterdam ……..One of my top three tunes of all time, but the memory behind it is mine and not for sharing!
So, what’s on your playlist?

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Julie Garton is an Alzheimer Scotland Dementia Nurse Consultant for NHS Dumfries and Galloway

Getting Home for Christmas by @fanusdreyer

I was 19 and imbedded deep in the Angolan bush as part of an ideological war we did not understand. What we did know was that we were ragtag soldiers, paratroopers deployed in counter-insurgency, but dressed in a mixture of South African, Cuban and Angolan uniforms, unshaved and unwashed for weeks, carrying a plethora of weapons, living more off the land than off our rations; a few had been sent home for injuries or for smoking pot. A few weeks ago we had lost Simon and Anton when they stepped on a vehicle mine. We wrote the odd letter home and I had informed my parents that I would not be home until somewhere in January.

And then we were suddenly flown out from the north Namibian bush back to our base in Bloemfontein, a 1000 miles away, for a wash, a shave and change of gear. We handed in equipment and were given a five day pass, released onto the streets outside Tempe on the afternoon of 23 December. My parents were at their seaside holiday 600 miles away, I did not know the phone number and had little money. So I decided to ride with my thumb, although hitching was not allowed in uniform; you had to stand quietly on the roadside and hoped someone safe stopped to give you a lift.

So, as I stood outside the gate in my step-outs, red beret on and Brassoed wings on my chest, another soldier stopped. He was going to Despatch near Port Elizabeth, to see his fiancée and their son, and I was going in the same general direction. So I got a lift in his Datsun 1200, through the southern Free State and Colesberg down to Middelburg in the Karoo, and he dropped me off at a junction just outside town that felt like the middle of nowhere. Even in midsummer the Karoo night air was getting cool by 9. The first car came past after 30 minutes of waiting; it was a big old Ford pick-up truck holding a farmer, his wife and three kids and he immediately stopped; I was thankful to be bundled in the back with bicycles and sacks, and got dropped off in Cradock, with streets that were totally deserted by 11 pm, two nights before Christmas. I had made up my mind to walk to the Police station and ask if there was space in the holding cells for a place to sleep when another car stopped and the driver asked where I was going. He, his wife and daughter were returning home to their farm near Bedford after an early Christmas dinner with friends, 100 km from home. When I replied that I wanted to get to Grahamstown they told me to get in; I was grateful. Their car was an old Opel Rekord, and they took me down to Cookhouse, well beyond the Bedford turn-off, where they dropped me off on the main road south, before making a 180 degree turn and completing their 80km detour, all to help a lonely soldier trying to make it home for Christmas.

By now it was 1.30 am, Cookhouse was completely dark except for a few streetlights, but I noticed there was a train station. I walked the km or so into town and went to wait on the platform, hoping to find a railway bench that would be more comfortable to sleep on than the ground. And then a slow train came past, I explained my predicament to the conductor and he told me to hop on. I got to lie down in an empty compartment and paid nothing. At Alicedale the conductor woke me up and told me to change trains to get to Grahamstown. Again I flopped down in a compartment at no charge and can still remember how cold it became with no blanket and air leaking in somewhere. We arrived in Grahamstown at daybreak and I walked south to the road to Port Alfred. It was another hour away by car. Just before 7 a vegetable lorry stopped and the driver shouted “get in junior”; he had been in the para’s a few years earlier.

Senior dropped me off at 8 am on Wednesday 24 December in front of my parents’ beach house. Mum was alone in the kitchen, saw my face through the lorry window and started shouting “Fanus is here”. Poor Dad thought she had lost it, with me being away in the bush war, and came running out to help her, but found me standing at the door. Then everyone appeared, brothers, friends, neighbours, the children in swimming costumes and the old people in pyjamas, with me sticking out like a sore thumb, still with the red beret on my head. The vegetable lorry driver sat there watching the reunion, then gave me a crisp salute and drove off. I had no gifts, no other possessions, but it was probably our best family Christmas ever. Three days later I flew back to Bloemfontein, with the prospect of a traumatic week to secure my release from the army to get to university, and scars to carry forever.

Fanus Dreyer is a Consultant Surgeon at NHS Dumfries & Galloway.

Crabbit Old Woman by @gbhaining

This poem was written by Phyllis Mabel McCormack 30/06/1913–10/01/1994. Originally entitled “Look Closer” she wrote it in the early 1960s for publication in the Sunnyside Chronicle, which was a magazine produced by the staff of Sunnyside Royal Hospital for circulation within the hospital. She submitted it anonymously as she felt it was critical of some of her colleagues. A copy of the magazine was loaned to a patient in a nearby hospital, Ashludie near Dundee. Before returning the magazine, the old lady copied the poem out in her own handwriting and kept this copy in her bedside cabinet. When she died and the staff cleared her belongings, it was found and, as it was in her handwriting, it was assumed that she was the author.

POEM  Please take a little time to read this, also the nurses response!

I first learned of this poem whilst undertaking my mental health nurse training in the late 1980s.

Gladys 1

This poem resonated with me, and, has stuck with me throughout my career. This led me towards “care of the elderly mentally ill nursing” as it was then called, and, ultimately to strive for the delivery of the best possible care for people with dementia, their families and carers.

Why Dementia?

Traditionally dementia has been the “business” of mental health services but if we consider the statement below, this confirms that wherever we work, whoever we are, at some point we are going to come in contact with a person who has dementia.

“Dementia is one of the foremost public health challenges worldwide. As a consequence of improved healthcare and better standards of living more people are living for longer. This means in Scotland that the number of people with dementia is expected to double between 2011 and 2031. This presents a number of challenges, most directly for the people who develop dementia and their families and carers, but also for the statutory and voluntary sector services that provide care and support. Over time we expect that a greater proportion of health and social care expenditure will focus on dementia, and there is evidence of that change already. There are no easy solutions and transformation will take time. This document sets out what we will do in the next three years.”  Scotland’s National Dementia Strategy 2013 – 2016

What was it like away back then?

Gladys 2 Crichton Hospital (William Burns 1834)

Well…. whilst I was training in the 1980s I had various placements with the Crichton Royal Hospital that had wards for people with dementia.

These were large institutional wards with nooks and crannies all over the place, they had nightingale dormitories and from an observational point of view were a challenge.

The wards included acute assessment and long stay and it was dependent on the stage of your illness where you were placed. There was little evidence (in my opinion) at this time of person centred care. People were well cared for but personal choices were limited.

We had charts for bathing, toileting, weighing, to name but a few.

We dished out meals of limited choice and drinks based on what we knew, however, I mostly prefer to drink coffee BUT do like to be given the option of having a cup of tea!

We had large sitting rooms where everyone was expected to congregate between getting up, mealtimes, toileting times, bath times and going to bed. The telly or some Scottish music was generally going on in the background.  

I want to stress that we didn’t think we delivering poor care, we weren’t. We were delivering the care that met the physical needs of people with dementia and had to do this because of the numbers of people we were caring for. 

So have things changed?

YES!

We no longer have large institutional wards for people with dementia. People with dementia are cared for within their local community. Gladys 3

We have memory clinics where people are assessed and diagnosed early. People with dementia are supported to take control of their care and treatment including planning for their future and determining their wishes.

We have commitment from the Scottish Government to ensure that all people including people with dementia receive excellent person centred health and social care.

We have national programmes to support this including:-

  • Scotland’s National Dementia Strategy            
  • Older People in Acute Hospitals
  • Dementia Standards
  • Promoting Excellence
  • People at the Centre of Health and Care

So……………….back to my point about dementia touching each and every-one of us.

Yes it will:  be it personally or professionally, be it in the work place or at home. We will all have to be prepared to care for people with dementia as our aging population grows and we all live longer.

My current role as Alzheimer Scotland Dementia Nurse Consultant is as a result of the commitment from Alzheimer Scotland, the Scottish Government and a fundraising appeal by Kay the Dowager Duchess of Hamilton.

Gladys 4 I am a small cog in a big wheel but I am working with my colleagues across the region and striving to make sure “we get it right for every person every time” and particularly if that person has dementia.

Gladys Haining is an Alzheimer Scotland Nurse Consultant working at the Mental Health, Learning Disability and Psychology Directorate of NHS Dumfries and Galloway.

Telephone 01387 244007 (internal: 36606)

email: ghaining@nhs.net

Dementia helpline: 0808 808 300    www.alzscot.org

Leadership in a digital world by @dtbarron

Over the past few weeks, because of various activities I’ve been involved in, I have been considering leadership within a digital environment, specifically related to social media. derek1

Instantly two questions spring to mind 1) what do I mean by leadership? and 2) what is social media?

Leadership

Malby in 1997 described leadership as “an interpersonal relationship of influence, the product of personal character rather than mere occupation of managerial positions”.   Bennis and Nanus add to this by described leadership as ‘influencing and guiding’ as having a ‘future focus’, a ‘vision for the future’ while remaining in the present.

The key aspects that interest me in relation to digital and social media leadership is the ‘interpersonal relationship’ and ‘influencing/guiding’ components of these descriptions.  To me they are key in my own engagement with social media, my own role as a leader.

Social Media

So, what is social media – it’s those FaceBook and Twitter things isn’t it, celebrity gossip and nonsense about what someone is having for their dinner?  Yes, these two systems are part of the social media landscape, and yes there are celebrities on them – however it’s so much more than that.  Perhaps you haven’t consider that the very act of reading this blog means you are engaged with social media albeit it in what can be described as a more traditional approach to it.

Social media is an overarching term describing a wide range of ‘platforms’ that enable people to interact with one another:

derek2  The infographic (www.fredcavazz.net) visually helps to describe the core aspects of social media.  NB the 2013 version of the infographic has been simplified into four categories, follow the link if you want to see the 2013 version.

The infographic shows clearly that social media has multiple uses and multiple systems to use depending on what it is you want to achieve, who you want to engage with and who you want to share your message with.

In this blog I only want to focus on one platform – Twitter and share why I use it.

Some stats

80% of the UK population access the internet on a regular basis

60% of the UK population have a smartphone

The sixth most used app on a smartphone is – the phone: behind SMS, camera, Twitter, Facebook and internet browsing.

These stats simply demonstrate we are living in a changing world, the landscape around us is a dynamic place where people are doing things differently, where engagement happens in ‘new’ ways.  We have a choice embrace these developing networks as leaders or be left behind.  To be honest, I know some people who are very happy to be left behind – is that you?  If it is, don’t worry social media isn’t for everyone, we went through the same ‘pain’ with email and some still don’t see the need for it – to be fair, why would they when we’ve still got pigeons?

Twitter

derek3  From my personal perspective I use a variety of social media platforms to engage with a wider community – Twitter, Google+ (struggle to understand it), WordPress (use it frequently), About.me (use it but not sure the point of it), Tumblr (just started to use it), LinkedIn (got it, but not sure why), Instagram (got it, seems pointless), Vine (too old to understand it or find a reason to use it) and even have a Facebook account (only post my blog to it – I’m not a fan!).  Some of them I don’t really understand and only have them because I’m curious what they do, others I use more frequently to share and shape opinion, to listen to the views of other healthcare professionals as well as people using our services.

My most used medium is Twitter which is a key engagement tool for me in sharing with a much wider community than I could every have hoped to do by ‘traditional’ means.  At an event I was at last week #techlearnscot @jonbolton used a quote from Douglas Adam’s  Hitchikers Guide to the Galaxy

 “I’ve come up with a set of rules that describe our reactions to technologies:


1. Anything that is in the world when you’re born is normal and ordinary and is just a natural part of the way the world works.


2. Anything that’s invented between when you’re fifteen and thirty-five is new and exciting and revolutionary and you can probably get a career in it.


3. Anything invented after you’re thirty-five is against the natural order of things.”

 We are all aware of the age profile of NHS Scotland (indeed Scotland as a whole) – perhaps Adam’s explanation helps us understand why I’m often told “I don’t do Twitter”  as it’s obviously against the natural order.  In fairness, since 35 was a long time ago for me, it might also explain why I don’t really understand some of the other social media systems I mentioned above.

I’ve been on Twitter for two years, the first six/eight months I didn’t tweet and only looked at it perhaps once a day or once every couple of days.  I now use it daily, I enjoy engaging with a wide network of people from across the world.  I get to share events as they occur and help to influence thinking of others, while also being influenced.

A key use for me is to access contemporary information, research and academic papers.  The fascinating thing for me is, as I now follow people who have similar interest e.g. mental health or leadership, I have information that is of interest ‘pushed’ to me, I don’t always need to go looking for it.  However it also widens my interests by having information ‘pushed’ to me that I ordinarily wouldn’t go looking for, simply being on Twitter has expanded my interests and knowledge.

Most of our conferences and events across NHS Scotland have twitter #tags, this allows me an insight into what is happening elsewhere when I am unable to attend.  I enjoy being influenced and challenged in my thinking, often tweets from conferences contain simple reminders of why I am a nurse – I never get tired of refreshing my commitment.

Hierarchies

Traditional hierarchies do not exist in the same way within the social media environment, access to people who you would not ordinarily have contact with are open to anyone (I blogged previously on this topic).  We work in a system that aims to be more transparent, to be more approachable to ensure we have people at the very centre of care.  Twitter is one more medium through which we can listen to the views of others – those using services, colleagues and the wider healthcare world.  Our new Director General and Chief Executive of NHS Scotland is on Twitter (@pag1962) why not open an account and connect with him today?

Quick tips

Open an account (free) add a picture and a short biography (my advice for those who are professionals is to identify yourself as a professional).

Find someone you know is on Twitter and look through who they are following – if anyone they are following is of interest then you simply follow them as well.

Check it once a day, just have a look, no need to tweet anything.  Retweet something that interested you, only once you feel comfortable do you actually need to tweet something original.

Enjoy it – and if you find you are not enjoying the interaction and the engagement, then simply stop.  At the very least you’ll have empirical evidence of why its not for you and not simply because your over thirty five! (NB youngster <35yrs can ignore the last statement).

Some suggestions to get you started:

  •  @kendonaldson
  • @hazelNMAHPDir
  • @personcntrd_DG
  • @jeffAce3
  • @davidTheMains
  • @weemac63
  • @dghealth
  • @ayrshirehealth
  • and of course my own Twitter account @dtbarron

A final thought – does anyone know what the sixth most used app on a smartphone is?  Tweet me for the answer – hope to see you on Twitter in the near future.

Derek Barron is an Associate Nurse Director in Mental Health at NHS Ayrshire and Arran. he is also the Editor-in-Chief of our sister (?brother) blog @ayrshirehealth

‘Rays of Humanity’ by Ewan Kelly

‘The glimpses, the rays of humanity that I received in the hardest of times ….kept me going.’

 Life working in the health service, whatever our role in clinics, wards, offices, corridors and health centres is far from easy in the twenty-first century – sometimes its downright challenging, even hellish.  So what keeps us going back for more each day? (apart from the need to pay the mortgage and feed our families!) A question I’ve often considered not just personally, but as a healthcare chaplain with colleagues I’ve supported over the years. More than that, I am now in a strategic role which involves promotion of wellbeing for staff as well as patients and carers across NHS Scotland.

There are lots of aspects of our lives and our work which may help keep us motivated and feeling fulfilled in our roles in the health service. What are they? What gets you up in the morning to go to work even when things are tough?

As a young greenhorn healthcare chaplain in my late twenties during my first month working in a large acute hospital in Glasgow, I was invited by an occupational therapist and a physio to come for a coffee to meet some of the folks they were working with who were adjusting to lower limb amputation. In the rehab gym I joined a bunch of ten or twelve folks who had paused from their physio for a coffee and a blether.  The idea behind the invitation was that I might provide some support during a period of loss, transition and adjustment in patients’ lives. Everyone who had gathered for coffee was invited to introduce themselves as the biscuit tin went round.  ‘Hello, I said, ‘I’m Ewan, I’m one of the chaplains who works in the hospital. I’m here to…’ Before I could say any more a wee fella in a wheel chair interjected, ‘Is that like a minister or a priest son…..do you do services on a Sunday. I’m not really intae that guff.’  ‘ Well yes, ‘ I replied, ‘ that’s part of what I do but most of my job is to be around and listen to people as they make adjustments and deal with changes in their lives.’  But my new acquaintance  was persistent. ‘Ach yon religious stuff causes more problems that its worth all that Proddie and Catholic stuff. Look at the trouble in Belfast.’  ‘Well’,  I retorted rather pompously ‘ the short services we have here on a Sunday morning are for everyone who wants to come….it doesn’t matter which fit ye kick with.’ ‘Oh aye,’ said my conversation partner with a twinkle in his eye looking down at where his two legs should have been, ’that’s no much guid to me is it now son!’

Ewan KI wished the ground could have opened up there and then and swallowed me up. However, everyone else, including my double above knee amputee friend, was roaring and laughing. I was  bright red with embarrassment   but the ice was broken. I was no longer a rookie chaplain, a minster or a priest, I was human …..like everyone else. Numerous coffees and conversations, as well as fun,  followed in subsequent months in the  rehab gym

The courage, the humour, the banter, the human interaction even when life is tough  and a struggle ….observing  that, sharing in that, remembering that  and being inspired by that is one of the reasons I get up on a cold January morning to go to  work in the health service.

Michael  Wilson, a psychiatrist and healthcare chaplain,  in the early ‘70s wrote a book called  ‘Hospital  – a place of truth.’  His basic premise was that hospitals or healthcare is a place where we learn not just how to care but how to be human. Patients, carers and our colleagues can be our teachers and they are often a source of inspiration and motivation.

However, what is it that that patients and carers receive in return from us as members of staff who share our humanity as well as our professional expertise and technical proficiency in our daily work? 

Two weeks ago I had the privilege of participating in the Scottish Conference of Cancer Support Groups at the Beardmore Conference centre in Clydebank.  I was exploring with the volunteers from cancer support groups from all over Scotland  what  the motivating factors were which prompted them to help others living with cancer.  One woman spoke up in the gathering of over a hundred  people.

’ The medical and surgical care I received during my cancer journey could not have been better. It was fantastic but it was the glimpses, the rays of humanity that I received in the hardest of times that kept me going. That is why I have volunteered to help support others.’

Patient experience (human interaction) as well as clinical effectivess and safety together impact on the personal outcomes of patients.  (Doyle et al 2013) http://bmjopen.bmj.com/content/3/1/e001570.abstract

And …..meaningful human interaction as healthcare staff enhances our  wellbeing too.

Ewan Kelly is a former Medical Doctor and is now Programme Director for Healthcare Chaplaincy and Spiritual Care at NHS Education for Scotland

The Listening Project by @fionacgreen

I was gutted when I read Professor Leitch’s blog – the idea of asking people “what matters to you?”Fiona1 was exactly what I planned for my Blog. I now had to convey my own pathway into this area in such a persuasive way

PRECONTEMPLATION

My journey (unlike Professor Leitch’s) did not begin in a formal Quality Improvement class with international experts in the USA but began in a more slow burning fashion right here in Dumfries and Galloway.

I arrived in Dumfries in the spring of 2004 –a newly trained consultant. My head was full of evidence-based treatments and guidelines combined with naivety and a genuine enthusiasm to improve diabetes care.

At that time empowerment, self-management and structured education were emerging as factors to improve outcomes in people with diabetes and other long-term conditions. Shortly after my appointment we were fortunate enough to be given funding from the Scottish Diabetes Group to pilot DAFNE. For those of you unfamiliar with the diabetes world DAFNE is not a person but stands for Dose Adjustment For Normal Eating and is an evidence based weeklong structured educated programme for people with type1 diabetes.Fiona2 Structured education means that there is a defined curriculum delivered using adult education theory and delivered by trained and peer-reviewed educators.

6-8 people with diabetes participate in each course and bring with them years of experience of diabetes – on a recent course within the room we had amassed 254 years of experience of diabetes

CONTEMPLATION

DAFNE didn’t just empower, educate and motivate those individuals with diabetes who attended but also provided our local diabetes team (myself in particular) a unique insight in what it was really like to live with diabetes. I listened with interest and a growing sense of shame as people with diabetes described their experiences of diabetes in hospital , the sense of foreboding they felt when they attended clinics – they felt chastised, felt failures and felt that they were not always listened to. They told us how seeing high blood sugars despite trying to balance food, exercise and insulin was frustrating and many said that they simply didn’t bother to test as the results made them anxious.

I listened and I learned and I reflected.

I learnt that our interactions with people were often more powerful than we realised but not always in the ways we hoped. I realised that we were often ineffective in promoting improvements in diabetes self-management.

I reflected on my own training -despite my knowledge of trials and guidelines I had little training in consultation technique and promoting behaviour change.

Somewhat shamefully over the years I had become very skilled at moving people away from topics that were important to them to focus on the topic of blood sugar which was what was important to me.

DECISION

I realised if we were to achieve continued engagement of our newly educated and empowered cohort of DAFNE graduates that this traditional medical model of diabetes clinics had to change

Alongside this realisation we became involved with our local psychology department who took on the task of teaching us the theory of behaviour change and demonstrating the use of motivational interviewing, Socratic questioning, functional analysis and other tools to help change unhelpful health behaviours. This training was further complimented and developed by the “Doing Diabetes Better” programme and PIDPAD (Psychology in Diabetes, Psychology and Diabetes) project funded by the Scottish Diabetes Group

The heart of the training was active listening and in particular listening to what was important to people.

Initially I struggled to use the tools- I worried about the time factor involved; I worried about opening up emotions that I was uncomfortable dealing with and it often seemed easier to stay in a traditional role but as I practiced more and began to see people with diabetes begin to successfully generate their own goals and solutions I knew that this was a way forward

LAPSE/RELAPSE

Behaviour change is difficult not just for people with diabetes but for all of us in all aspects of our lives and just like the people I see in clinic I have found that old habits die hard and I know that when I am tired, stressed or running late I don’t always listen as well as I should or apply the tools I have learnt as effectively as I should.Fiona3 In these circumstances I find myself slipping back into my comfort zone of focussing on blood sugars, targets and guidelines but through the increased self- awareness I recognise these factors and try to avoid dictating care plans

Finally I suppose it is important to know whether it has made a difference-I now have a better understanding of the reasons why people find it difficult to implement and sustain changes to improve health and wellbeing. I know that I now find clinics more tiring -exploring thoughts and feelings in relation to diabetes is emotionally exhausting but the things I hear and results I see encourage me to continue.

By changing from what from “what’s the matter?” to “what matters to you?” patient satisfaction scores have increased significantly as has HbA1c (a marker of blood sugar control)-both of these improvements matter to me.

Now when a consultation takes a diversion into areas unrelated to diabetes I stick with the diversion as I realise what I hear matters to us both

Dr Fiona Green is a Consultant Endocrinologist and Diabetologist at NHS Dumfries and Galloway

Next week we will have a joint blog from myself (@kendonaldson) and Peter Bryden (@peterbryden1) summarising the recent Enhanced Patient Experience Event.