Let’s insist on the possible by Valerie Douglas

Many things in life are complicated, require great debate and despite huge resources are not guaranteed to be successful in practice. There are other things which are simple to understand, can easily be implemented and immediately make a difference to improve lives or in some cases save lives. You only have to think of the meaningful campaign to change the care of people with a diagnosis of dementia led by Tommy Whitelaw (Tommy Whitelaw @tommyNTour). It makes sense and it hits you in the heart. As a professional you cannot listen to Tommy talk about caring for his mum and withhold your support for this campaign. His mum is your mum.

Another example is Kate Grainger’s inspirational campaign (#hellomynameis). This focuses right in on the doctor/patient relationship. It goes further than just making us think more about face to face contact with patients who may feel vulnerable, distressed and in alien surroundings. It asks us to look at our practice on a basic level, to say our name aloud, on every contact. At one point this patient was Kate Grainger but the patient could be any one of us.

Last November an important, widely supported campaign for the mandatory teaching of Cardiopulminory Resuscitation (CPR) to schoolchildren was unsuccessful. This Emergency Bill was opposed despite irrefutable evidence that it saves lives. In Norway it has been compulsory for schoolchildren to be taught CPR since 1961 and survival rates are double what they are in the UK. As out-of-hospital cardiac arrest is the commonest life-threatening emergency in the UK so I thought this campaign was bound to be fully supported and unchallenged. You can imagine my disappointment.

I felt at a loss about what to do next, yet felt there had to be a ‘next’. To increase survival rates of cardiac arrest the immediate action of bystanders is crucial. Personally I have carried out CPR three times, twice in a hospital setting and once at a family event. A day of laughter and pleasure turned into tragedy. Event though, as a nurse, I’m aware that the outcome from CPR is variable for a myriad of reasons, I was left affected by this last experience. Then a doctor said to me, “If I had a cardiac arrest I would want someone to have a go.” I am glad I have been taught CPR and am able to ‘have a go’, otherwise the most I could have done that night would have been to phone an ambulance instead of giving a friend a chance of life.

What could I do now? I decided to put together a resolution to RCN Congress 2016 calling on governments to mandate the teaching of CPR to schoolchildren (the remit of the Emergency Bill had been wider, encompassing all kinds of First Aid). The resolution was accepted and I presented this in June this year.

There were wide ranging contributions to the debate. Personal stories were shared about children delivering CPR successfully. A delegate told us about a situation where his 27 year old teammate collapsed during a game of football. 23 players including the referee were there and nobody knew how to do CPR; this man died. He went on to describe a more recent experience when an instructor was brought in to teach CPR to the junior football team. Within 10 minutes they were doing it perfectly.
Some delegates expressed concern about the effect on children if they delivered CPR and it was unsuccessful. Others answered this by saying: remove the fear, teach them young. The evidence is there. Someone else highlighted again that encouraging CPR lessons in schools as an add option is not enough; teaching needs to be a requirement so that there is no national disparity. Kate Ashton made a very acute observation at Congress:
“If we can educate youngsters in schools about sex education and creating life then surely we can educate them about saving lives.”

Every year an estimated 60 000 out of hospital cardiac arrests occur in the UK (BMJ 2013;347:f4800) It could happen to any one of us. What can you do?
Write to your local MP and express your support for the campaign to mandate teaching of CPR.
Become a local First Responder.
Find out if your town/village has a defibrillator and where it is kept.
Ask your school if the teaching of CPR is on the curriculum.
Let’s insist on the possible.

Valerie Douglas is a Staff Nurse in Mental Health at Midpark Hospital, NHS Dumfries and Galloway

Health and wellbeing – How do we get it right? by Catherine Mackereth and Michelle McCoy

Not one of us has had a choice in the life circumstances into which we were born. We are born in a country, with particular parents and with certain advantages and possible disadvantages – and this can have a lifelong impact on our health and wellbeing. We know that some are born with genetic conditions that have a huge effect on their lives; those brought up in poor housing conditions are more likely to suffer from respiratory diseases; children brought up in care may have less resilience to overcome difficulties (which is not to say that many don’t overcome them); and many are not able to make the most of opportunities because of the difficult and challenging circumstances they find themselves in.

Within Public Health, a discipline that has a major focus on seeking to improve health and wellbeing at a population level and reducing inequalities, a model that we often use to describe these situations is the Dahlgren and Whitehead rainbow (below). This, since its publication, has become a frequently used model for describing the underlying causes of ill health in the population and provides a helpful framework on which much of the health improvement work we are involved in is based. It offers a social model, which focuses not just on the individual lifestyle factors that impact on health, but on the wider socio-economic, cultural and environmental conditions, which make a huge difference to our health and wellbeing.

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Underlying these differing life circumstances are inequalities which may be income, education, housing, environment or social conditions. The graph below shows how health and social problems are worse in more unequal countries. These inequalities can be found with regards to child wellbeing, levels of mental illness, drug use, life expectancy, infant mortality, obesity, teenage pregnancy, education, to name just a few.

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These inequalities are not inevitable, and therefore should be tackled in order to ensure people have opportunities to improve their health and wellbeing. It is the role of Public Health and all our other partners to address these issues. It is not an easy task nor can it be undertaken by one agency alone.

Improving health and wellbeing must be supported at all the different levels identified in the rainbow model above. At an individual level, we need to understand why people behave in the way they do. Much of our work in improving the populations’ health and in providing preventive services is about supporting people to make their own positive life choices. However, having the ability to make choices is something not everyone has to the same extent: the very reason why we need to support people. For example, at one level, people have the choice as to whether to smoke or not. But if you are under stress, giving up smoking might be one thing that is too difficult to contemplate: we know that will power is a finite resource, and if you are juggling with a crisis, then all your efforts need to go into solving that crisis. And that is not even considering the physical addiction and the impact of tobacco withdrawal. Remember, very few people actually want to be addicted to cigarettes.

Health and wellbeing also needs to be addressed at a family level. For example, we know that some children are disadvantaged at school entry because they do not have the necessary emotional, social and cognitive skills which enable them to take advantage of the opportunities available from education. Support for parents can provide the self-confidence and self-efficacy to help counteract these difficulties, so that children can have the best start in life. This is extremely important for future life when these children become adults, and affects further wellbeing and subsequent use of health and social care services.

There are many approaches to supporting improved outcomes for population health. For example, at a wider level it is important that environmental issues are addressed. Creating enough green space for children to play or adults to walk and be physically activity can have a major impact on health and wellbeing – as can having nutritious food available locally, or accessible social activities. Having enough money is also a key element of trying to live healthily. In times of job insecurity and rising costs, this can be challenging, so ensuring access to the right kind of advice for claiming benefit, offering support to complete job applications, provide welfare rights information to support people to claim what they are entitled to, providing accessible health services and health information which is easily understood, is vital.

If, as a society, we are to reduce the burden on health and social services, we must work together to prevent and mitigate against the circumstances which act together to limit the ability for communities and individuals to achieve optimum health and wellbeing. There is a lot that can be done to support people’s health and wellbeing, and this must be underpinned by looking at what people themselves really want, not just assuming that we, as health professionals, know what is best for them. We need to listen and understand where people are coming from, and do that with compassion. We all want the freedom and autonomy to do what is best for ourselves, and we need to make sure we support people in achieving that for themselves.

Catherine Mackereth is a Consultant in Public Health and Michele McCoy is a Consultant in Public Health and Interim Director of Public Health at NHS D&G

 

Island reflections by Heather Currie

Holidays are for fun, relaxation, recharging the batteries, catching up, all things good. But holidays also give time to think and reflect and often holiday situations trigger a thought which may have relevance to a work situation. I think that’s ok, I don’t think I’m pathologically workaholic. I enjoy having time to reflect, whether that be on holiday or other.

heather-jettyA recent holiday in the beautiful west coast, triggered reflection on how we respond to patient’s needs, and perhaps how we could do better.

On the west coast of Mull is a ferry which goes to the tiny island of Ulva. While waiting to take a boat trip out to the Treshnish Isles (home of a huge colony of wonderful puffins), I noticed the sign indicating how to summon the ferry. No regular routine service, just a board with a moveable cover. Move the cover, red board shows, ferryman on Ulva sees red board, ferry sets out. Simples.. Ferry there when needed and when summoned. Receptive and responsive. It made me think whether or not we are receptive and responsive to our patients’ needs and what about the needs of the relatives?  A few examples make me think perhaps not enough?

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In recent times my mother in law sadly suffered from a stroke and was in an acute hospital for several months before being transferred to a Rehab unit and subsequently a nursing home. Being a patient is always a humbling and learning experience, as is being a relative and visitor of a patient. On one visit I was concerned that her finger nails were quite long and dirty. “Mum” could not speak at this stage but since she was always very particular about her appearance, I knew that this would cause her distress and asked the nurse in charge if it was at all possible, please please, thank-you so much…(it felt like asking for anything was a major challenge) could her nails be cut. To my surprise and disappointment, I was told that this was not possible since only two nurses on the ward had had the “training” and when they were on duty it was unlikely that they would have time. Receptive and responsive or too rigidly bound up in rules and protocols of questionable evidence base that basic needs are not met? Thereafter we took it upon ourselves to cut the nails ourselves!

I was very reassured on return to DGRI that this would not happen here and strongly believe that we are more receptive and responsive, but could we do better?

Recently, one of our gynaecology patients who had been diagnosed with a terminal condition was moved between wards four times as her condition deteriorated. As long as her medical and nursing needs were being met, was it fair on her at this sad stage to have so many moves? Did we really think about what was best for her and her family and were we receptive to their needs?

In outpatients, how often do we ask patients to return for a “routine” appointment when they may not need to be seen in six months time, but have problems at a later date? Could we instead be able to respond to their needs and see them or even make telephone contact when really needed?

An elderly gentleman understandably complained because he spent a whole day travelling from the west of the region to Dumfries by patient transport, for a ten minute outpatient appointment to be given the result of a scan. In his own words, “he was not told anything that could not have been told by telephone”.

What routine investigations do we carry out that are of limited clinical benefit, often subjecting patients to yet further unnecessary investigations because of slight irrelevant abnormalities?

When questioning our practice, let’s also be prepared to be curious about that of others in hospitals to which we refer—recently a patient was referred to Glasgow for a gynaecological procedure. The procedure went well but the patient subsequently contacted me concerned that she had been asked to return to Glasgow for a follow up discussion. She wondered if a phone call would be possible in view of the huge inconvenience that this appointment would cause. I wrote to the consultant and asked if this would be possible. His rapid response was enlightening and reassuring: he had always brought patients back to a clinic as routine practice and never considered an alternative. He promised that from then on he would offer all such patients a telephone follow up instead.

Let’s use common sense and be prepared to challenge and bend the rules. Remember the ferry. While we do not have a “ferryman” waiting to respond at all times, we could consider the 4 “Rs”and be –

Responsive not Rigid,

Receptive not Routine.

Heather Currie is an Associate Specialist Gynaecologist and Clinical Director for Women and Sexual Health at NHS Dumfries & Galloway 

 

 

 

 

 

 

 

Are you an Improver? by Paul Sammons

I caught a bug back in 2008 – the Patient Safety bug. I caught it when I became involved in the Scottish Patient Safety Programme. I have kept it and cultivated it ever since.
Before that time I thought that rapid cycle improvement was something about new carbon fibre bicycle frames!

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OK so I was wrong – as an ex banking project manager, I knew loads about change, but was hit with the realisation that in the past we did things to people rather than with people, and used hierarchy to make people do as they were told. A bit like inviting folk round for dinner and telling them what they will enjoy eating. Not the best recipe for embedding change.
And so I was smitten, with the likes of Jason Leitch talking about the lens of profound knowledge, small tests of change and measurement for improvement.
After a sabbatical into NHS IT work, I became an improvement advisor, and saw that the same bug had visited Dumfries and Galloway and taken hold, with lots of measurement and improvement going on, aimed at process improvement and reducing harm to patients.
But see this Model for Improvement methodology and all that goes with it – is it portable? Can it be used where there are no doctors?
In 2016 I am lucky enough to be supporting a new improvement collaborative, working with 5 dental practices to apply the set of improvement related tools and principles to address the question – does dentistry harm patients? Well there is risk of getting it wrong in all walks of life, and dentistry is no exception. Since we are people, dealing with other people, we may be able to address unnecessary harm, reduce variation in processes and improve communication. To anybody who has teeth – this matters.
This opportunity allows me to support dental practices to identify where they want to focus their improvement efforts, apply the Model for Improvement methodology and see if the concept works.
The dentists enjoyed a learning session around improvement methodology, and collaborated to agree an aim around improving the quality and use of medical histories in dentistry. Locally we built a process map so the practices involved could see, and discuss where medical histories matter. We saw a number of areas where a medical history influences treatment planning, for example diabetes, allergies and certain medicines. Dentists, hygienists, nurses and practice managers agreed measures that we could use to track the improvement journey, and to feed into improvement conversations.
The methodology tells us that measurement should continue objectively all the while we identify and test change theories – ideas that may (or may not) result in improvement.
The theories in the model for improvement are logical and simple to use. Say for example, if we need to know if a patient takes a medicine called a bisphosphonate – and we don’t actually ask that question on the medical history form – might it be an idea to change the way we ask for the information? Well it might – but how do we know that any change actually improves anything?

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The methodology suggests that we don’t waste time implementing ideas that might not work. So the practices might say, change the form for one patient, and determine if the change worked for that patient. If it did they might try with say 5 patients, redesigning and refining each time. As the theory develops the form is likely to get better, and spread to a wider group. Eventually, if the small tests of change go well, the change might be adopted across the practice. And if the collaboration aspect does its job the change would be available for other practices to try out for themselves.
So six months into this application of the Model for Improvement, I have to say I m completely convinced that it has the potential to deliver small changes that will collectively result in significant improvements, as well as developing the collaborative culture within and across practices.
OK so I am sold on the benefits of the Model for Improvement, and in my role I am lucky enough to spread its virtues daily.
But that’s me. What about you?
What I do see is that when folk are granted permission and have capacity to take part in improvement work – they love it. But rarely is it seen as part of their every day workload, and the skills that make it happen are not often embedded in the team or the individual. So as an improvement advisor it may be that when I walk away the focus on improvement activity can reduce.
So the skills, knowledge and experience needed to take part in or lead an improvement project – do you have them? Do you know what they look like? Would you have the confidence to lead an improvement project – and do you have access to the support that you might want to secure?
I truly believe that these capabilities should form part of everybody’s role. So it is with that in mind that I would love to do myself out of a job. If everybody could do this work, then I would not be needed – right?
What gives me the most pleasure is when I leave the room knowing that the people I work with no longer need an improvement advisor. That they can run small tests of change, that they can measure the effectiveness of, and the variation across processes, and use the results to discuss and promote improvement in their team, and also that they don’t rely on hierarchy to determine whose ideas are considered.
Right now the Patient Safety & Improvement team have a programme on offer called the Scottish Improvement Skills programme where many of these skills are offered. You may have seen the flyers across Dumfries and Galloway. Applications close on 30th June however, so you may need to get your skates on! This is a great way to prepare for involvement in improvement work – and to do me out of a job!
Do I not like my job I hear you ask? Well with my involvement in the dental collaboration I am lucky enough to see this cross fertilisation of capability unfolding before my eyes every day. Now that’s job satisfaction for you. Long may it continue!

Paul Sammons is an Improvement Advisor with NHS Dumfries and Galloway

Change…. Didn’t we do that program already? by Neil Kelly

“The Only Thing That Is Constant Is Change -”
― Heraclitus

How often have we now heard that the challenges we face can only be resolved through transformational change?  It seems we are in a constant state of flux with management structure changes, team developments, policy statements and strategy.  So does it feel as though these changes are transformational? Although we have this feeling of constant reorganisation I suspect we are all still inherently conservative and hope that if everyone else changes then we can keep our own ‘show on the road’.  Our natural anxiety of change being disruptive helps us to keep our heads down and hope that the process will pass us by and things will settle down as they so often have in the past. This defence mechanism has served us well in until now but is about to be found wanting. In Primary Care (as in the whole of the public sector care giving service) we face the ‘perfect storm’ of even increasing demand, a dependence culture generated by our desire to ‘do good’, a crisis of man power with unfilled posts for GPs other clinical staff and especially carers and significant financial pressures which continue having already ‘trimmed all the fat’ over the last 4 years.

It trying to deal with the’ impending dooms day scenario’ we have been doing multiple tests of change, PDSA cycles and participating in all the latest Scottish Government and Health Board initiatives in an attempt to reshape what we do.  We have gathered a lot of information about how good some of these initiatives have proved to be.  However now we seem stuck.  How do we convert all this ‘learning’ into the transformational change we all desire? Certainly our approaches until now do not seem to have delivered for us.

At the core of what we do as a service are the people who are toiling every day to provide the care demanded and recognising the pressures trying to work harder, faster and smarter.  We are literally ‘sweating our assets’. The eternal busy-ness has resulted in silo working and fragmentation of teams.  So we now need to pick up our bits of learning, coordinate our approach to care, re-establish our community based teams and begin a very different sort of relationship with the communities we serve. In Annandale and Eskdale we will establish in the first instance 4 community groupings of health and social care staff with third sector and independent service providers. These groups will work closely with public health teams to better understand the needs, prioritise and plan services more in tune to those needs and negotiate amongst themselves how this can best be achieved.  In other words everyone involved will take a bit more responsibility for what they do.  The users of the service will be encouraged and enabled to care more for themselves, family members will take a bigger role and everyone involved will be geared to working towards those aims.

So how do we make this happen?  We need to invest in and support collective leadership and ownership, allow much more autonomous decision making and allow the team to monitor its own success. This is a change in approach which is just beginning and will be challenging and uncomfortable at times.  It may feel like just another ‘dip in the change water’ but this time it really needs to transform what we do.  This is applicable to everyone and this time there will be nowhere to hide.

“No man ever steps in the same river twice, for it’s not the same river and he’s not the same man.”
Kelly 1― Heraclitus

Dr Neil Kelly is a GP in Annan.

‘How I survived change’ by Kirsty Bell

I read a quote recently that inspired me to write this blog

“It is not the strongest of the species that survives, nor the most intelligent. It is the one that is most adaptable to change”.

That is evolution, and I suppose in my opinion and to be black and white about it, when it does comes to evolution, those who adapt survive and those that don’t – may feel it’s forced, become extinct.

So how do we respond to change? Whatever form that change presents – it changes your life in some way or another.

Change is inevitable throughout our lives. I have gone through various events in the last 5 years which changed my life forever, so here’s some insight into how it effected me but most importantly, how I survived.

I married my first husband Colin in September 2011, a very happy day and one that lives with me every day. Six week later, on my birthday, I had a knock on the door where two policemen presented. Seconds later, they told me my husband had suffered a heart attack and had tragically died; he was only 36, my life changed forever.

And goodness, did my life change. I felt utter fear of what was ahead of me… how will I cope? I don’t want anything to alter or be different, I just want it to stay the same, I need him back, I am just married, it’s a mistake, someone please change it back to how it was, nobody understands…. This isn’t my normal!! This was just to name a few…….

Actually, I think I went into autopilot and wasn’t really aware of how I was behaving as I was more focussed on surviving. So are we working on autopilot when it comes to change and do we recognise how we come across to others?

So to answer my first question; how do we respond to change? – Well obviously we are all different and it varies, some people don’t like change – they like things just the way they are, where others can adapt to change well. We all respond differently and there is no right or wrong in the ways how we react, everyone is an individual.

I also ask myself the question do we respond differently when it’s forced or voluntary change. For me, the death of Colin was forced, however, I had to learn to adapt to the change by relying on support from friends, family and colleagues to ensure that I wasn’t making any major decisions as a reaction to the change (well I tell you that was some task for them), also asking for help and most importantly me accepting it.

Through time I found the strength to actually accept the change and knew who I was again, sorry actually who I had become without Colin. You know, Colin was so full and happiness and positivity, and if you know me, that is certainly the legacy he left with me when he died.

To put into context, I have talked about how I adapted to enforced change but since then I have very much embraced change and moved on. I met my now husband, Ewan in 2014 and at that point, I just knew that is was right and felt so happy, I actually couldn’t believe that I could feel like that again. I embraced my changes I re-married and moved away from my home town. I suppose what I am really trying to say is the changes that I had previously experienced, however hard, really helped me to recognise and adapt to change which made me into a much happier and stronger person.

So following on from this I do believe that we master the art of change over our lifetime of experiences which provides us with a great advantage and more importantly we learn about ourselves and how we respond to change.

I have learnt in some pretty hard lessons in life, and no matter how much we want our lives to stay the same – it just isn’t going to happen, we need to embrace it, become part of it, and make the changes inspire you.

My final word really, if you do feel yourself confused and lost in the process of change. Share any concerns, confusion and talk about it. Remembering it’s an individual’s desire to change that drives them — and that’s how I survived.

Kirsty Bell is the Clinical Change Programme Project Manager for 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.

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It might need

Guts-More fight

Grit-More passion

Gumption-Being courageous

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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

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Easy to say

Perhaps harder to achieve

But unstoppable when it starts

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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