‘Docere’ by Sonia Cherian

The word ‘Doctor’ is the agentive noun of the Latin verb Docere which means ‘to teach’. The title ‘Doctor’ refers to a person who is recognised to have acquired sufficient knowledge in a subject to be a teacher of that subject. The role of the doctor as a teacher helps educate patients about their condition. A well-informed patient is crucial to the success of any treatment plan. In an era of increasing demands on the healthcare system coupled with  changing patient expectations, the doctor’s role as a teacher has a unique significance.

The supreme court ruling in the Montgomery case (Montgomery v Lanarkshire Health Board, 2015) was a watershed moment from a medicolegal perspective. Mrs Montgomery, a small built diabetic patient had complications during a vaginal delivery which resulted in her son being born with severe disabilities. The case hinged on whether the health board had provided her with all the information which could have helped her make a decision between a normal delivery or a caesarean section. Her obstetrician felt that the risks of shoulder dystocia during normal labour was not significant enough to discuss with her thinking that this information may have resulted in the patient choosing a caesarean section which had its own risks. The supreme court felt that had the risks been explained fully to the patient, she would have opted for a caesarean section and the baby would have been born unharmed. This ruling established that a patient should be told whatever they want to know, not what the doctor thinks they should be told. Mrs Montgomery was awarded a compensation of £5.25 million and the ruling fundamentally changed the law on decision making with the transition from ‘medical paternalism’ to ‘patient autonomy’. The ruling makes it clear that any intervention must be based on a shared decision-making process ensuring the patient is aware of all options and supported in making an informed choice by their healthcare professional.

The General Medical Council (GMC) document on Good medical practice advises to work in partnership with patients:

• You must listen to patients, take account of their views, and respond honestly to their questions.
• You must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs.
• You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.

(https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/domain-3—communication-partnership-and-teamwork#paragraph-46)

The Realistic Medicine agenda led by the Chief Medical Officer (CMO) of Scotland makes shared decision making and a personalised approach to care its key themes. (https://www.gov.scot/publications/practising-realistic-medicine/)

‘The King’s Fund’ research recommends that patients should be given a chance to take an active role in decisions about their care and treatment by providing the right opportunities, information and support. Services should reflect the needs of patients by meaningfully involving patients and carers in service commissioning, planning, design and improvement. (https://www.kingsfund.org.uk/publications/shared-responsibility-health)

An informed patient can positively contribute to decision making regarding a personalised approach to his or her treatment. This would also mean that patients are more open to share the responsibility of these decisions and be prepared to live with the consequences of their choices thus reducing the risk of complaints and litigation. Patient decisions are not only influenced by medical considerations but also by non-clinical issues which are of relevance to that individual patient. Values, beliefs and life experiences that have a personal significance can influence choices. Our role as clinicians is to support the patient in the decision-making process by providing expert medical advice through a dialogue. Unlike emergency situations where decisions have to be made quickly to save the life or limb of a patient, the vast majority of treatment decisions are taken in primary care or in an elective setting in secondary care. Many conditions have a variety of treatment options, each with its own benefits and risks. In some situations, having ‘no treatment’ is also a reasonable option.

Many patients are well-researched about their condition having read various articles on ‘Google search’. However, for a non-medical lay person to comprehend the vast, often confusing and sometimes contradictory online information can be challenging. This may leave patients with incomplete and out of context information. Hence the information that the patient could assimilate online is quite different from the knowledge that he or she needs to make personalised treatment choices. The clinician has the unique role as a teacher to help transform the information the patient has into knowledge whereby safe personal choices on treatment could be made.

Discussion regarding the various methods of Patient education is a topic on its own and is beyond the scope of this blog. Though innovative ways to deliver succinct information using digital media seems to be the way forward, these would never replace the warmth and compassion of a caring competent clinician who would help patients make the right balanced choices. This would only be possible with the provision of time and resources to improve meaningful information sharing during consultations.

The CMO’s annual report (2016-17) acknowledges that the main barrier to healthcare professionals having more in-depth discussions with patients is the issue of time. “Simply offering the standard treatment or investigation may be quicker, but not necessarily what is in the patients’ individual best interests. It is essential that in order to provide high quality, personalised care clinicians are in a position to make the time to have these important discussions. If we are able to move towards engaging in these conversations as a part of routine practice, it is likely this will in some circumstances save time where patients decide against investigations or treatments that they do not feel are right for them.”

The second Citizens’ Panel Survey (August 2017) revealed that the behaviour/style of the doctor and how busy they are (or are perceived to be) had an impact on patients’ inclination to ask questions. The current legal and regulatory requirements make it the responsibility of the clinician to provide adequate time to the patient so that they are well informed prior to making a decision.  However, the Scottish Public Service Ombudsman (SPSO) has commented in the CMO’s Annual report (2016-17) that this responsibility is not that of the clinician alone. This process would require policy changes within the organisation and a change in culture that encourages and fosters patient centric multi-disciplinary team working.

The GMC guidance, the Supreme court ruling, the concepts of Shared decision-making, Patient centric care and Realistic medicine all point to the pivotal role of patient education  thus highlighting the importance of what it truly means to be a doctor : ‘A Teacher !’

Therefore, let us all remember to ‘teach before we treat !’ and support each other in patient education with the ultimate aim of delivering holistic patient care.

 

Dr. Sonia Cherian is a GP at NHS Dumfries and Galloway as well as a GP Appraiser and CPD Adviser at NHS Education for Scotland

 

 

 

The Paper Boat by Patricia Cantley

I’ve been reading a lot recently about the word Frailty and its importance within Medicine for Older People. We see a lot of frail people and as geriatricians they are our core business both inside and outside the hospital.

Healthcare professionals have debated over the last few years how to define Frailty, and even how we might begin to measure it. It is no longer adequate simply to shrug and say “we know it when we see it”.

From a patient or relative’s point of view however, the word Frailty seems to be at best somewhat vague and at worst, derogatory and demotivating. When we ask patients how they feel about the word, whether in large surveys or on a one to one basis, they do not like it.

One strategy that I have found useful over the years, especially when talking to relatives of the patients under my care, is to paint a picture that they can relate to by using a simple analogy. I’m sure others have used similar techniques – indeed I learnt this one from a consultant colleague many years ago.

So when I am talking to a family member about their older relative, I sometimes liken their clinical situation to a fragile yet beautiful paper boat sailing round a pond of their choice.

A while back I used this particular strategy for a very elderly man under our care who was going through a very complex and unstable time. At one point, there seemed to be a lull in the medical winds that were buffeting his fragile frame and I sat down with his daughter to chat things through. She was desperately seeking reassurance, but also wanting honest facts about what to expect over the months to come.

She smiled as I described my image of a beautiful paper boat, brightly painted and currently sailing proudly in the sunshine on the still pond, giving pleasure to all around. I explained that the difficulty was in not knowing what weather was ahead, and the problems forecasting accurately. If the weather were to remain fair with barely a trace of wind, then there was no reason to think that the boat would go down and indeed it might sail on for quite a while. If, on the other hand, the wind got up, or worse, if it started to rain, that frail wee boat would go over quite quickly with little we could do to save it.

As younger and healthier individuals, we react more like little tug boats of wood and steel… we would simply bob up and down until the storm had passed. Though a big enough hurricane could be too much for us too…

The chat developed a bit more as we translated some of this into more medical language and formulated a plan over what would and wouldn’t be reasonable things to try, should that wee boat capsize over in a high wind. We agreed that we’d want to try as much as we could, maybe including intravenous therapy but that at the end, a call to the family rather than futile attempts at CPR would be the right strategy. I noted it all down, and his daughter undertook to update the rest of the family.

As is the way in modern medicine, our paths diverged and he was discharged from our service. I didn’t keep in touch, though I knew his daughter had my mobile that she could call if she wished.

Many months later, a text came through…

“Dearest Trisha, I am sending this sad message to you to let you know that last night the paper boat went down in a storm. It was all very sudden at the end, but we were well prepared, and for that we thank you.”

I called the patient’s daughter later that afternoon and we chatted about what had happened. I don’t think we used the word frail at any point in her father’s journey, but she knew what we meant, and I think it did help. It was also lovely to be able to talk afterwards and listen to how the last chapter of the story had unfolded. It is rare as hospital doctors that we get to do this kind of post bereavement support and for me, it was well worth while being home a little late (again) that evening.

Every doctor I’ve met has tales of when things go well, and we all have our share too of when they haven’t. We must never be complacent, and a strategy that works with one family may not work with another.

We need to learn a lot of facts as doctors, but there is also an important place for the use of stories in medicine. We can learn and teach what has worked for us, and consider how others might adopt and adapt similar approaches.

I had another text, more recently, from a previous trainee. Also a happy story, they wanted to tell me of a scenario in another hospital in another city, where they explained to a family the fragility of another paper boat. Intense medically focused discussions had failed to convey the precarious nature of the situation, but the visual image of a brightly painted origami boat had been something of a breakthrough. I was touched by the kindness of the younger doctor that they thought to feed back to their former teacher in this way.

I’m still not sure what the best way to define Frailty is, but I’ve tried a few ways of describing it in the clinical situation. I’d love to hear tips from other people, in particular from patients and relatives, about what has worked best for them.

Patricia Cantley works as a consultant physician in the Midlothian Hospital at Home Team, offering an alternative to hospital admission for frail and older patients. She also works in the Royal Infirmary in Edinburgh and in the Community Hospital in Midlothian. She tweets under her married name of Elliott as @Trisha_the_doc

This blog originally appeared on the British Geriatrics Society blogsite on the 9th July 2018. Many thanks to Patricia for the permission to republish on dghealth.

Get up, Get dressed, Get moving by Amy Conley

Think about an older person, someone in their eighties – let’s say it’s your Granma…

Your Granma lives in her own house; she’s not quite so good on her feet anymore, but she gets about OK.  Stairs are difficult but she manages – and she manages to get up and dressed, make her breakfast and her tea, feed her cat, read the paper, get to Tesco in the car with you.

Then your Granma gets ill – she has say, a chest infection.  She is admitted to hospital.  You pack her bag – nightie, toothbrush, comb.  She is admitted to the ward – she is poorly, needs antibiotics and a drip for a few days. So, on goes the nightie and your Granma is in bed; that’s what you do in hospital – you are poorly and tired and you need to rest in bed.

Your Granma is in bed in her single room.  She needs the toilet but doesn’t think she should get up by herself – she is a patient in a nightie so needs help.  But she can’t see very well or hear very well and can’t find her glasses or hearing aids.  She can’t find the buzzer to buzz the nurses and she can’t hear when they are near.   She thinks maybe she could get herself to the toilet, but she can’t see her walking sticks and is scared she will fall. 

Time passes.  Your Granma is incontinent in the bed.  She is embarrassed and frightened – what will the nurses think?

Now she is scared to drink and eat because she doesn’t want to need the toilet and be incontinent again.  And she doesn’t want to bother anyone.  The physio comes to see her, tries to get her up.  But she is still embarrassed and frightened.  She has no clothes to wear.  And she has only those foam slippers she got from the nurse.  So it’s best just to stay in bed.

Your Granma stays in bed for longer and longer.  There is nothing to do.  There is a TV but she can’t see it or hear it without her glasses and hearing aids.   She is getting mixed up now; she can’t remember when she came here or why or what day it is.  She thinks she can see cats in the corner of her room.  She still won’t eat, so she has no strength and feels weak. She doesn’t want to get up.  Her bottom and back hurt.  Her leg has swollen up – they said it is a blood clot.

The physios keep coming back.  They try to get her up; two of them struggle to get her to stand.  She is stuck in bed. 

Your Granma’s chest infection has been treated and she has no acute medical illness, but now she is immobile, confused, dehydrated, incontinent, her muscles are weak and she cannot walk anymore, or get herself washed or dressed. 

Your Granma is not going to manage at home anymore; she has to go to a care home.

 

“GET UP, GET DRESSED, GET MOVING”

At DGRI, we are launching our campaign on Monday 23rd July– the aim is help our patients maintain their function, mobility and independence while in hospital, and for them to return home as soon as possible, as able as possible.

 

WHY HAVE THIS CAMPAIGN?

• Most patients in hospital are over 65
• In hospital, older people spend up to 83% of their time in bed
• 65% of people’s functional ability declines during admission
• 60% immobile older patients in hospital have no medical reason to stay in bed
• If you are over 80, 10 days in hospital ages muscles by 10 years
• 1 week of bed rest equates to 10% muscle loss
• These changes are “deconditioning” –  “reconditioning” takes twice as long

WEARING YOUR PYJAMAS IN HOSPITAL

• Affects your confidence and self-esteem
• Changes how you interact with healthcare staff and other people
• Is usually unnecessary no matter why you are in hospital
• Doesn’t feel very dignified when you are trying to eat your dinner

 

STAYING IN BED IN YOUR PYJAMAS

• Reduces muscle strength
• Reduces confidence
• Reduces function
• Increases blood clots, delirium, pressure sores and infections
• Leads to reduced appetite, low mood and anxiety
• Reduces social interactions
• Lowers pain thresholds
• Can make blood pressure drop
• Causes constipation and incontinence

WHAT CAN HEALTHCARE STAFF DO?

• All of us can and should help patients get moving – nurses, doctors, AHPs, porters, domestic staff, pharmacists…
• Ask the patients how they normally get about and what they normally do
• Make sure patients can access buzzers, water, remote controls
• Encourage patients to get dressed and sit up in the chair

 

WHAT CAN PATIENTS DO?

• Tell us how you normally get about and get things done and what you need to help you
• Try to do things that you do at home – wash and dress, eat and drink on your own if able
• Sit up in your chair and for meals
• Drink lots
• If you can’t get out of bed, do little things – wiggle your toes, do a crossword – every little movement  helps

 

WHAT CAN VISITORS DO?

• Tell us what you do at home
• Bring in glasses, hearing aids and walking aids
• Bring in comfortable day clothes and well fitting shoes
• Encourage you to sit up in the chair and for meals
• Take you for a walk
• Bring in photos, books, puzzles, crosswords

THE BENEFITS

• Speeds recovery
• Reduces time in hospital
• Encourages patient and carer involvement in healthcare and recovery
• Helps to retain patients’ individuality and self-esteem
• Helps patients to quickly return home, mobile and functional

 

If you or your family are worried that it is not safe for you to get up or you might do the wrong thing – ASK US!  We will tell you what is safe and OK for you!

#endpjparalysis

#goinghome

Amy Conley is a Consultant in Geriatric Medicine at Dumfries and Galloway Royal Infirmary

‘What I am told I forget…… by the Renal Team

…what I am shown, I remember.

              …what I do, I understand.’

Confucius was credited with many words of wisdom in his 72-years.  I couldn’t vouch for the authenticity of them all – but if he did utter these words he was indeed a man before his time.

The truth behind these words was apparent to me at our recent Kidney Care Planning Education day. The Kidney Care Planning Service has undergone a bit of a re-incarnation in the last couple of years. Formerly known as the Pre-dialysis service, it is simply the care of patients with an eGFR of less than 20mls/min, as they are more likely to progress to end stage kidney failure and need to plan for such an eventuality. However, the term ‘pre-dialysis’ implies that these people are all heading towards dialysis – when in fact many will choose an alternative path. The younger fitter patients should be hoping to get a pre-emptive kidney transplant from a relative or friend, while some of our elderly, frailer patients may well not benefit from dialysis at all and will survive just as long on conservative (nondialytic) care. So when Tanya Harkness took up the mantle of lead Nurse for the pre-dialysis service, she quite rightly felt a new name was required. Many renal units use the term Low Clearance Clinics, but a straw poll of non-renal staff suggested this was more reminiscent of a rehabilitation clinic for inattentive bus drivers… So, after much discussion amongst the renal team, the more accurately named Kidney Care Planning (KCP) service was born.

The aim of the service remains unchanged and while we do take bloods and treat symptoms, easily 80% of what we do is talk. More specifically we provide as much information as we can to help every person decide which treatment option is going to suit them best. We do this with clinic visits and home visits. We provide information leaflets, website addresses and even YouTube videos – all with the aim of imparting information. Yet still we are sometimes asked a question that blindsides us – that either leaves us thinking ‘How did you not know that from all the conversations we have had?’  or ‘Crikey- that’s a good question that I have no idea how to answer!’ Because at the end of the day none of us handing out this information have ever experienced what they are going through – the actual treatments, the fear and anxiety, the dread of what their lives will become or the understandable desire to block it all out and pretend it’s not happening.

Which brings me back to Confucius! The subject of teaching is vast, with as many different approaches as there are pizza toppings. Yet 500 years BC, Confucius nailed it with this simple truth – when we actually do something, we come to understand it. So who better to teach our patients, than other patients who have been in the same boat.

We have held education days in the past, usually in a hotel function room with talks given by members of staff. Tanya was keen to resurrect the concept, but made it quite clear from the outset that there was ‘No way on God’s earth’ I think was the phrase that she was ‘EVER’ standing up in front of a room full of people to give a power point presentation. (Why not, I have no idea as I am sure she would be excellent….but there we are!)

So a new format was devised between the whole community team – a less formal approach, like an open day, where patients could turn up and wander at will from room to room – talk to the team leads, watch demonstrations, see the equipment and most importantly meet other patients.

The date was chosen to coincide with a visit from Ewen Maclean, Kidney Care UK Patient Support and Advocacy Office, Scotland. Ewen, himself a renal patient, is a mine of information about the support available to kidney patients, grants and how to apply for them and the political landscape that shapes kidney care in the UK.

We no longer had need of a hotel function suite – if there is one thing we are not short of at Mountainhall it’s space! (And the parking is pretty easy too – sorry!!) So, we sent a personal invitation to all our KCP patients, laid on refreshments and opened up the old pre-assessment unit for the day.

The Renal Community Team (Left to right): Fiona Gardiner (Renal Dietitian), Robert McLemon (Transplant) Ian Mottram (Haemodialysis – both home and in-centre), Wendy Brown (Peritoneal Dialysis) Margaret McDonald (Clinic Health Care Assistant & Phlebotomist), Linda Stiff (Vascular Access), & Tanya Harkness (Kidney care planning).

As well as written information everyone had something practical for patients who attended and the responses we had were truly illuminating. Ian had a haemodialysis machine with all the lines and bucket of dialysis fluid set up and received the comment ‘Oh, I didn’t realise it would be so small-I assumed it’d be really big.’ And why not –historically dialysis machines took up a whole room, which must be a really intimidating thought if you are going to be hooked up to one- but it has NEVER occurred to me to comment on the size of a dialysis machine in my many dialysis related conversations.

Robert had asked 3 transplant patients, with more than 50-years of experience between them to attend. I am not sure if any of them showed their scars where the transplant was placed but they had experienced all the ups and downs of transplantation and immunosuppressants so there was no glossing over the bad bits.

Linda was showing patients how to feel  their fistula and what to listen for – explaining how the noise it makes can change if a stenosis is forming – and she was able to give those with a fistula their own stethoscope to involve them in their own fistula care.

Our renal dietitian was also on hand to give practical advice on managing fluid balance, as well as providing visual aids on potassium, phosphate and salt restrictions-something that renal patients universally struggle with!

One of the biggest successes of the day came from Wendy who had persuaded one of her Peritoneal Dialysis (PD) patients & their families to come and chat so they finally actually knew what the PD catheter looked like when it was inserted and could see for themselves how an exchange worked. But more importantly they could ask someone having the treatment what it felt like, how it impacted on their lives, whether it interfered with their sleep, whether it actually helped! One of our patients who had been set on coming to the hospital for haemodialysis when his time comes, has now changed his mind. We have been sure for many reasons that he would be best suited to PD, but fear was driving his decision. One hour watching a gentleman of his own age performing an exchange and listening to his stories of how life continues almost as normal around PD, has achieved what 5-years of reassurance from us could not…

The feedback Tanya received was overwhelmingly positive, but patients are generally nice, so it is the more subtle signs that have persuaded us this is the right approach. The questions and comments patients have since made in clinic prove that they have valued and retained some of the information they learnt that day. One patient commented how reassuring it was to see dialysis patients who looked well and still lived a normal life. And I hope through this some of the fear for the future has abated.

I expect in the future we will still be blindsided by hitherto unasked questions, but it is not only the patients who are learning, as I finish with yet another Confucius quote:

‘He who knows all the answers, has not been asked all the questions!’

We would like to express our sincere gratitude for all the patients and families who came that day, especially for those who came to share their experiences with patients in the early stages of their kidney care planning journey. We are also grateful for the patients who gave their consent for us to take photographs and use them in this blog.  We hope to make “Kidney Care Planning Education day” an annual event from now on.

 

Other useful renal websites:

Patient focussed resources:

Kidney Patients UK / The National Kidney Federation, the largest kidney patient charity in the UK, run by kidney patients for kidney patients, website provides lots of useful information.

Kidney Care UK – formerly the British kidney patient association, very helpful brochures available online.

Think Kidneys – NHS England’s campaign to raise awareness of the importance of kidney disease. Lots of useful resources can be accessed with just a few clicks from this page.

Clinician focussed resources:

Renal Fellow Network – A USA based website with worldwide contributions distilling vast amounts of renal knowledge into bitesized articles, a great resource to start learning about renal medicine.

UKidney – online education on Nephrology, hypertension and kidney transplant.

#NephJC is a fortnightly Twitter-based Nephrology Journal club with visual abstracts, free access to the articles provided by major journals and regularly includes participation by the authors and other worldwide experts in the field.

 

This blog was written by Dr Alison Almond, Associate Specialist in Nephrology, with contribution from rest of the Renal Team, NHS Dumfries and Galloway.

 

Dietitians do Prevention by Laura King

Next week sees the return of Dietitians’ week and the theme this year is ‘Dietitians do Prevention’ with each day having sub-themes. Follow #DietitiansWeek on Twitter, Facebook and Instagram for some insights into our involvement in a wide and varied range of preventative activities.

Here in NHS D&G we have dietetic teams working across these areas which may come as surprise to the majority of folk working in the acute hospital who perhaps associate us mainly with artificial feeding and oral nutritional supplements for those who have scored 2 or more when nutritional screening is done on the wards.

As a small team we recognise that we have to play a role in educating and enabling patients, their families and carers to prevent over and under nutrition by supporting self-management, the dietitian can’t come shopping with you, cook your meals and help you to eat them and make the best choices, so we have to rely on using our communication skills to educate and inform patients and those close to them to help have a healthy, balanced diet that meets their needs.

We factor in ‘what matters to you’ and our assessments incorporate a huge range of factors as this poster illustrates:

Our Team works in the following areas all of which have significant roles to play in prevention:

Community Nutrition Support  (Kerry, Alexandra, Jackie, Jennifer, Lis, Dillon and Carole) – We provide practical, evidence based dietary advice, specifically tailored to each individual. Through dietary advice we aim to prevent and treat a wide range of medical conditions and empower people to make appropriate diet and lifestyle choices. Community Dietitians see patients in a variety of settings including community hospitals, nursing and residential homes, clinics and patient’s own homes. Our role identifies, prevents and manages malnutrition in the community. We liase with individuals to create realistic and achievable goals to optimise/improve their dietary intake.

Various medical conditions require an individual to be provided with their nutrition via a tube. We are responsible for managing these patients in the community, either in their own home or in a nursing home/community hospital setting.

We deliver educational talks on various topics including cardiac rehabilitation, stroke, Parkinsons disease and pulmonary rehabilitation.

Renal (Fiona) – Supporting patients with advanced kidney disease in managing complex nutritional requirements. Preventing further complications that can arise from inability to excrete electrolytes and fluid overload as well as avoiding weight and muscle loss for this group of patients who have increased requirements for protein once dialysis has commenced.

Gastro (Gemma and Sarah) – Preventing complications from poor management of coeliac disease such as the obvious GI disturbances through to the ‘hidden’ consequences such as increased risk of bowel cancer and oesteoporosis. Supporting patients living with inflammatory bowel disease to manage their symptoms and optimise their health and well being. Preventing the often crippling effects of irritable bowel syndrome by supporting patients to use the low FODMAP diet to identify trigger foods and modify their diets in a safe and sustainable way.  Preventing malnutrition in liver disease which is often masked by fluid shifts.

Paediatrics (Mhari, Anne and Tracey)  – Supporting parents & their child in managing children with complex needs, tube feeding, diabetes, gastroenterology issues, cystic fibrosis, weight management, faltering growth and allergies – preventing short and long term consequences of under nutrition.

Diabetes (Katy, Nicola, Sally, Sheena, Wendy): We are an integral part of the diabetes multi-disciplinary team providing a dynamic and evidence based service. We deliver quality assured education, and aim to support patient driven care and safe self management to those living with diabetes and their family. We also provide continuing education and support for health care professionals working with individuals with diabetes.

Weight Management (Katy, Nicola, Sally, Sheena, Wendy): We provide person centred, safe and evidence based advice to individuals with complex needs and requirements. This encompasses a variety of approaches to help aid weight loss and improve quality of life.

Mental Health and eating disorders (Sam and James) – Supporting recovery from mental health crises and from the consequences of living with disordered eating behaviours.

Catering (Debbie)- Working with Catering to achieve menus for inpatients across the region that offer a varied, balanced diet to support their recovery and prevent complications such as poor wound healing and  pressure ulcers. Also ensuring guidance for Catering teams to create therapeutic or special menus for patients’ individual dietary requirements. Training staff who make and deliver food, fluid and nutritional care to patients in hospital.

Acute (Laura, Anneka, Laura, Jennifer, Laura and Sheree) – seeing patients identified as being at risk of undernutrition to assess their individual needs and support recovery. Preventing increased length of stay, poor wound healing, pressure ulcers and other complications of malnutrition and providing advice for discharge to help patients stay well and continue their recovery once home with or without the support of the community dietitians as appropriate.

All this activity is coordinated and supported by our Head of Dietetics (Lorna).

The acute team are planning to pilot some staff education sessions on B3 and D7 to support ward staff in preventing malnutrition as well as identifying the patients who need our one-to-one support, so please get in touch with Dietetics on 01387 241568 if you would like to know more, want to arrange any training on your wards or if you have any questions about this blog post and what we do.

Meanwhile here are some pictures of the acute team (Anneka, Jennifer, Laura and Laura) ….

Laura King is Lead Acute Dietitian at Dumfries and Galloway Royal Infirmary

Summer of Celebrations Part 1 by the SPSP Team

Reflections from Improvement Advisor, Paul Sammons

As an improvement advisor with no clinical background, I work closely with people who want to change things for the better, and who know their teams and roles well, but who don’t always have the skills to structure improvement work.  They may not have the capability to use the ‘model for improvement’ – a proven methodology that helps focus aims, identify change ideas and to measure what difference if any, a change actually makes.  Having completed the Scottish Improvement Leader programme (ScIL) in 2015/16 I do have that capability which, when brought together with practitioners who have a will and an urgency to change things for the better, can be very powerful.   I enjoy the privilege of working alongside, enabling, and learning from some fantastic individuals and teams who strive to improve services of their patients and service users.

Some of these moments will be with me forever – I recall working with Dr. Grecy Bell to motivate and enthuse a group of primary care staff about Medicines Reconciliation – not the most lively of topics, but Grecy created the ‘med rec fairy’ concept – a local champion in each GP practice who would carry the ‘wand’ to ensure their team saw med rec as a vital part of their work.

Another great memory for me was working alongside Dr. Mark Colwell – we teamed up to lead a local dental improvement collaborative, creating a structure around better decision making and treatment planning for patients on high risk medication.  Mark showed me how ceding power to his team enabled a flat hierarchy where all team members were able to critically observe each other’s practices, and contribute towards a more collaborative approach to patient care.   With the practices involved we improved much – starting even before patients arrived for their appointments – maximising the use of text messaging, moving through the patient’s journey. The work involved reception staff to engage with patients to obtain highest quality patient histories, and enabling dental nurses to observe and to prompt their bosses into even better patient conversations.

I have observed people in health and social care who once invigorated with a little QI magic, will stop at nothing to deliver better care, and who seem to have the energy to drive improvement forward in the most unlikely circumstances.  I spend time with Julia Hutchison in DG Smile dental practice, and I leave with a real spring in my step.  What is it about these people and all of the others that I get to support that is courageous, different and special?  I do reflect on a wee video that helps me answer that question.  You might like it too.  It is available on YouTube and can be viewed here.

I believe that attention to QI capability and capacity is key to improving services, and that we will see this develop through our local ever-expanding network of QI capable practitioners.  In the near future we will expand our practitioner level QI education and training – to ensure managers and leaders are well equipped to support, coach and supervise improvement projects.  In 2018/19 I plan to focus improvement efforts into the Women’s and Children’s teams as they settle into their new DGRI home.  I contribute to the improvement force field that is growing stronger across Dumfries and Galloway in health care and in social care.  I work as part of a small but wonderful team of hand-picked curious and quirky individuals – who quietly and tirelessly support each other, creating a synergy of support to our customers.  Perhaps you are close to that growing network of improvers – perhaps you feel the force like I do?  Well I do, and as I work with a widening spectrum of fabulous people I can honestly say that there is much joy in my work.  Long may it continue…

 

Take Two Bottles Into The Shower? Not me, I’m a Clinical Health Psychologist by Ross Warwick

Because you’re worth it

Bang! And the dirt is gone!

Eat fresh

I’ve been thinking a lot about advertising these past few weeks as September is a significant time for my team in Clinical Health Psychology. This month we will be making a concerted effort to promote our service, raise our profile and increase our contact with the people we aim to help.

As part of this, Ken has kindly allowed us to take over the blog for a few weeks. I’m kicking things off with an account of what the service does and I thought I would take inspiration from psychological tricks used in the world of advertising to help draw you in and get the message out there.

I’ll start, then, with a summary of the service that follows the advice of a Professor of Experimental Consumer Psychology at the University of Wales, Jane Raymond. Prof Raymond advises that rather than bombard the audience with information I should break it into chunks to allow the brain time to process each component:

• Chunk 1: The Clinical Health Psychology service helps people who have a psychological problem that is caused and maintained by a physical illness.
• Chunk 2: These problems usually involve unpleasant feelings and unhelpful thoughts about the illness that keep someone from doing things that matter to them.
• Chunk 3: This can cause distress, affecting overall well-being, medical treatment, self-management and health outcomes

An article in a social psychology journal showed that a wide range of people respond well and are persuaded by stories (Thompson and Haddock, 2012). So to illustrate chunks 1-3 here’s a fictionalised case based on real events:

“Jane is a young teacher who has type 1 diabetes. Her condition and the things she must do to keep on top of it are often accompanied by feelings of shame, anger and loneliness. She has frequent thoughts that her condition means she is abnormal and that it must be hidden from others. Because of these unhelpful thoughts and feelings she avoids testing her blood, guesses her insulin levels, is inconsistent with her diet and keeps problems to herself.

She has been absent from work and in and out of the DGRI several times within the past twelve months. Because of this she believes friends, family and colleagues are annoyed with her for not taking proper care of herself and landing them with more responsibility. As a result, she avoids seeing people and has become more and more isolated.”

The next steps for Jane are chunked below:

• Chunk 4: In therapy we would work with Jane to live well with her condition by addressing her unhelpful thoughts, feelings and avoidant behaviour
• Chunk 5: As therapy is all about collaboration, Jane’s most likely to have a good outcome if she’s motivated to participate and make changes to her life
• Chunk 6: Jane can be referred to Clinical Health Psychology by anyone who is involved in her care, be it her GP, Practice Nurse, Dietician, Diabetes Specialist Nurse or Consultant.

In Jane’s story, she’s in and out of DGRI because thoughts and feelings stop her from acting in a way that would help keep her well. So psychological therapy would add value by reducing her distress and unplanned contact with services (and by highlighting that sentence your attention has been focused on a key message about how psychology makes a difference to both the person and the hospital; Pieters and Wedel, 2004).

But would you believe that individual therapy expertly delivered by members of our experienced, compassionate, and, yes, attractive, team is but one feature of our service? In Clinical Health Psychology we also provide training, teaching, supervision and consultation because you don’t need to be a psychologist to provide psychological care (worth mentioning because (a) it’s completely true and (b) according to Goodman and Irmak, 2013, audiences are likely to prefer multi-featured products).

Already the Diabetes and Cardiac Teams are benefitting from increasing their psychological knowledge and skill through participating in Emotion Matters training, and a group of local GPs have recently completed training to introduce CBT techniques into their routine consultations. Recruitment of a second cohort will be underway soon.

Time for pictures of the product:

By now thanks to my evidence-based and scientifically informed techniques of persuasion, you will no doubt want to know how you can benefit from working with our wonderful service.

You can contact us by email or by calling us at the psychology department to talk about matters psychological, be it complex cases, potential referrals, or training your department. Find out more about making referrals by consulting our service leaflets which are available absolutely FREE through Beacon by searching for ‘Clinical Psychology’ or looking under ‘Documents’ after following the link below. And as the Patient Information Leaflet can also be found there, you enjoy a 2 for 1 bonus!

http://hippo.citrix.dghealth.scot.nhs.uk/sorce/beacon/?pageid=Sitesearch&searchCriteria=clinical%20health%20psychology

Keep your eyes open for opportunities to attend training events we’re delivering this month and enjoy the blog posts written by the Clinical Health Psychology team over the next few weeks. Finally, to eke this advertising ruse out just a little further, comment below to be part of a Clinical Health Psychology virtual focus group.

Just do it.

Ross Warwick is a Consultant Clinical Health Psychologist and Lead for Clinical Health Psychology at NHS Dumfries and Galloway

What a waste! by Dot Kirkpatrick

It cannot have escaped your attention that the media has been writing about food waste. The Guardian recently reported the latest figures, showing that UK households are throwing away £13bn of food each year. This equates to 7.3m tones of household food waste. Of this, 4.4m tones were deemed to be avoidable. This set me thinking about my own food waste. I can honestly state that apart from the occasional out of date yogurts caused “buy” 2 packs for £3 scenario, I either cook and freeze or make the ingredients into soup! I am not precious about sell by dates unless associated with a dairy product, fish or chicken, apart from when I am having people for dinner! I can’t be poisoning the guests? A plaque in my kitchen states… “Many people have eaten here and lived!”

This brings me around to the purpose of this blog. Medicines waste. I feel a bit of a turncoat as I have given many a presentation clearly stating that you cannot compare the difference between Kellogg’s cornflakes and a supermarket cheaper own brand with branded drugs and their generic equivalent. However in this instance there is an analogy.

A report by the Department of Health estimates that unused medicines cost the NHS around £ 300 million every year, with an estimated £ 110 million worth of medicines returned to pharmacies, £90 million worth of unused prescriptions being stored in homes and £50 million worth of medicines disposed by Care Homes.

These figures don’t even take into account the cost to patient’s health and well being if medications are not being correctly taken. If medicines are left unused, this could lead to worsening symptoms and extra treatments that could have been avoided.

Due to the complexity of the causes of medicines wastage, a multifaceted and long-term approach across all healthcare sectors is required including partnership working with third sector organisations, public health, voluntary groups and local councils.  Coming to a surgery, pharmacy, library, council office near you soon, will be posters(designed and printed by our local council)  letting you know that each year in Dumfries & Galloway, we waste £3m worth of medicines of which over half is avoidable.  Look out also, for twitter feeds, Facebook postings and press releases. The posters and social media messages will attempt to engage with the public on how we can work together to reduce medicines waste. Simple tips such as “Only order what you need”; “Check before ordering”; “Don’t stockpile medicines” will feature in our waste campaign. With £3m required to be saved from our drugs budget this year, we cannot afford to ignore the unnecessary cost of waste.

Waste campaigns have been featuring on the Prescribing Support Team’s remit for many years. There was Derek the Digger whose sole purpose in life was to pick up medicines waste by the ton. Then there was our Big Red Bus Campaign. We had a range of items with catchy slogans e.g. erasers stating “Wipe out Medicines Waste”. Last but not least was our ferret, carrying a bag of drugs out of which coins were leaking and going down a drain This time our Waste Campaign will be ongoing. The posters will change, the messages will vary but our mission will stay the same. Medicines cost money and we do not have an endless supply of resources. We need to use our allocated funding for medications where it will benefit patients by improving health outcomes.

And back to the analogy. I must admit that my husband randomly buys jars of chutney despite having adequate supplies in the cupboard. There are far worse faults and I can live with that.  I however know what is in my fridge/cupboards/freezer and so I don’t stockpile resulting in wasting food supplies. I think what I need, I buy what is necessary and I don’t buy items that I don’t want. Simple no waste!

It is everyone’s responsibility to promote the messages around using medicines responsibly and I hope we can rely on your support by promoting our campaign.

Dot Kirkpatrick is a Prescribing Support Pharmacist at NHS Dumfries and Galloway

I walk and cycle to work because I’m lazy by Rhian Davies

It’s true, I’m lazy. If I didn’t travel on foot or by bike to work, the shops, the pub, I’d need to find the time, inclination and means to exercise. So I walk and cycle because it:

• Gets me there

Walking is the oldest form of transport. In fact we’ve evolved to do it – having been walking around for about 1.9million years. Cycling has been a means of getting from A to B for nearly 200 years.

• Gets me there quickly

No searching for car keys, waiting in traffic and finding parking spaces. A journey by bike in Dumfries takes about the same time as a journey by car. Walking or cycling on traffic free and quiet routes means I don’t get held up by queues and stay clear of road works.

• Saves time

No need to find time to get to the gym or go for a run as travel is my exercise. Most people say they would exercise more if they had the time. As I’m travelling anyway, that time is put to use as exercise time too.

• Is enjoyable

The main thing for me is the fresh air, being outside and enjoying the wildflowers and wildlife that I see and hear, especially at this time of year. Winter has an upside too – no need to get up early to see a beautiful sunrise and the moonrises can be pretty spectacular too. I’ve also seen shooting stars on my way home from work. And despite what it feels like, it doesn’t rain that much! In fact, there’s a 95% chance of NOT getting rained on, on your way to work.

• Is sociable

I often see people I know on the way and enjoy having a chat with them. Waving to the lollipop lady on the way to work or chatting with the nice man who walks his spaniel adds a little happiness to my day.

• Is safe

The most recent figures from the Department of Transport show the fatality rate for pedestrians and cyclists is the same, with one death per 29 million miles walked or cycled. Looking at how many people were killed or seriously injured, it works out at one person for every 1 million miles cycled and one person for every 2 million miles walked.

• Keeps me fit

The main difference compared to driving is that whenever you walk or cycle your health benefits, whereas remaining seated in a car does nothing to improve it. Typically I cycle to work, a 20 minute journey each way, which easily meets the guidelines for 150 minutes of moderate exercise a week.

• Benefits people and planet

You only have to look at the news and you’ll see an almost daily report on worsening air pollution and the effect this is having on people and the environment. Walking and cycling isn’t the only way to tackle this problem but it is a difference we can make every day to the people and place we live.

• Is easy to get parked

In my role as Active Travel Officer, I’m here to help anyone who is thinking of travelling by foot or by bike. I’m working with staff at DGRI, the new hospital, Crichton Hall and The Willows.

Over summer I’m running events including basic bike maintenance workshops, Essential Cycling Skills, information stalls on route finding and guidance on buying a tax free bike through Cyclescheme. Upcoming events are posted online and advertised in the core briefing and posters around DGRI, Crichton Hall and The Willows.

So if you’re feeling inspired come along to:

Bike Maintenance for beginners

Drop in session – not sure how to change an inner tube? Need to know how to check your bike is safe to ride? Find out how and have a go.
Monday 22 May and Friday 26 May: 12noon – 2pm and 4pm – 6pm

Venue: Garage 26, the hospital residences

Cyclescheme information stall

Come along to find information on applying for a tax free bike

Crichton Hall Canteen on Tuesday 23 May: 12 – 2pm

Essential Cycling Skills (Beginner)

Can’t remember the last time you’ve ridden, or feeling wobbly when you ride? This is the course for you. Please book here.
Part 1 Wednesday 24 May: 11.30am – 1pm, Part 2 Thursday 25 May: 11.30am – 1pm

Part 1 Monday 5 June: 5pm – 6:30 pm, Part 2 Tuesday 6 June: 5pm – 6:30pm

Meeting point: Garage 26, the hospital residences 

Essential Cycling Skills (Intermediate)

Are you happy cycling on quiet roads but not sure how to navigate roundabouts or junctions confidently? Then this is the course for you. Please book here.
Part 1 Wednesday 24 May: 5:30pm –7pm, Part 2 Thursday 25 May: 5:30pm –7pm

Part 1 Wednesday 7 June: 11am – 12:30pm, Part 2 Thursday 8 June: 11am – 12:30pm

Meeting point: Garage 26, the hospital residences 

Bike Security Marking

Thursday 1 June: 12 – 2pm and 4pm – 6pm

Meeting point: Garage 26, the hospital residences 

I also want to hear from you about what would help you get out and about on two feet or two wheels. Are there facilities or infrastructure improvements that would allow you to walk and cycle? Have you heard about electric bikes but never had a go on one? Just let me know!

Contact me on:

rhian.davies@sustrans.org.uk

Mob: 07788336211

Tel:  01387 246246 EXT: 36821

 

Rhian Davies is an Active Travel Officer for NHS D&G

Lochar North

Crichton Hall

Bankend Road

Dumfries

DG1 4TG

 

 

 

 

 

Can I make a difference? by Paul Gray

It’s a big question – can I make a difference?  How does it feel to ask yourself that?  For some of us, the answer will be different on different days.  My experience suggests that your answer depends much less on what you do, than it does on how you feel.  In this blog, I’d like to offer some thoughts on making a difference.

However, some context first.  I fully recognise the challenges we face.  Health budgets are going up – but pressures on recruitment, and the demands of an aging population, are also very real.  There is also still much to do in tackling inequalities, and improving the health of the population, which NHS Scotland can’t do on its own.  And we do know that people have the best outcomes when they are treated and cared for at home, or in a homely setting.  So our current models of care are transforming to meet these demands, and to provide the most appropriate care and treatment for people, when they need it, and change brings its own challenges.

So my first suggestion is to turn the question, “Can I make a difference?” into a statement – I can make a difference.  If you start from that standpoint, you’re much more likely to succeed.  It’s easy to become pre-occupied with the things we can’t change, and the barriers and problems – I know that I fall into that trap from time to time.  But wherever I go, I see people throughout the NHS, and in our partner organisations, making a difference every day.  So ask yourself, what is the one thing I can do today that would make a difference?  And then do it!

Now, give yourself some credit – think of an example where you did something that was appreciated.  Write it down and remember it.  If you’re having a team meeting, take time to share examples of things that the team did, that were appreciated by others.  Sharing these examples will give you a bank of ideas about simple things that matter to other people.  And it also gives you something to fall back on, if times are tough.

Next – think of an example when someone did something for you, which you appreciated.  Find a way to share these examples too – if it worked for you, it might work for someone else as well.  Ask yourself when you last thanked someone for something they did well, or something you appreciated.  It’s easier to go on making a difference if others notice what you’re doing!

If you’re leading or managing a team, ask yourself how much time the team spends discussing what went well.  It’s essential to be open and transparent about problems and adverse events, but if that’s the whole focus of team discussions, we overlook a huge pool of learning, resources and ideas from all the positive actions and outcomes.  And we risk an atmosphere where making a difference is only about fixing problems, rather than about improvement.  So, as yourself and your team, what proportion of time should be spent on what went well?

Remember to ask “What Matters to You?”.  I know that the focus of this question is on patients, and that’s right because they are our priority, but it’s a good question to ask our colleagues and our teams as well.  Just asking the question makes a difference – it gives you access to someone else’s thoughts and perspectives, and is likely to lead to better outcomes.

Will any of this change the world?  Not on its own, of course.  But you could change one person’s world, by a simple act of kindness, or listening, or a word of thanks.  You can make difference!

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